Chain of custody form, Sep 2001

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM cchester WESTCHESTER COUNTY LABORATORIES AND RESEARCH ■ Uuncen:i 2 Dana Road, Valhalla, New York 10595 94) 593-5575 NYS-ELAP No. 10108 l ime/Date Set: N Form A-70 (rev.1/96) SRpletype (circle one): ______

1. Potable ) 13, Non Potable Treated ] Bottle 66 " C2+2222-2H4AL/— /24-2. 2.Non Potable 4. Other__________ ___ Chain of Custody?yes___ no Time/Date Collected:__ _ r 1 Comments:__ Collected By: D __ ____________ Agency Code: - PWS #: _ Source ID: ____Type Descriptor:____ " Collected From:■ Bill to: Location’s/Individual’s Name ...................... _ Name/Company.... Street__ L2... 1J2M -.....b4 4 i2. Street________ City/St/Zip ‘ ai a L £ 4 _ a.A City/St/Zip_______ Identification of S'OUrce Collection Point _ •d Phone#:____ I ax':

CA.CH, Bl? -...._ Check#: Amounts

5A*8l6i 60* ANALYSIS ORGANIC POTABLE ANALYSIS OB'. NQNPOTABLF080 ANALY:S Lab#; (circle tests) 1. Heterotrophic Plate Count (hemodialysis & all others) Lab#:___ (circle tests) 1. Trihalomethanes (524) MS (2.) Volatile Halocarbons (524) I :■ i : * :s ■ Biitit, ahome (id’h) I. MAmty i.i 2. Coliform P/A (public supplies) 3.olatile Aromatics (524) 3. Acrolein & Acrylonitrile (624) • 3. Coliform MPN (priv well, raw, stp) 4. Total Trihalomethane Potential (510) :4. Phthalates (625/8270) 4. Focal Coliform (all samples) 5. Microextractables (504) 5 Organochlorine Pesticides (608/8081) I ' Microscopic 6. Pesticides (507) 6. PCB’s (Arochlors) (608/8081)' Macroscopic (7.Pesticides/PCB screen (508) .7. Methoprene (616) ZPl Gher___ _ 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151) 9. Herbicides (515) .9. Pesticides (SM18/6630) Refrigerated? ves ano I "10. Pesticides (525) FIi Culiatn, I ‘02* madi • i i . 11. Glycols it xtslettoliytloutal,Gran jo I.'.’:

Chlorinated:? ves no 12. Glyphosate (547) 12. Acid Extractables (625/8270) 13. Diquat (549) 13. Base Neutral Extractables (625/8270) Free Chlorine Rest mg/L 14. Chlorination Disinfection Byproducts (551) 14. GC/MS Semrvolatile Unknown Scan Total Chlorine Res: 15. Haloacetic Acids (552) 15. Purgeable Halocarbons (DEF) . mg/L 16. Pesticides (SM 18/6630) 16. Purgeable Aromatics (DEF) pH . 17. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB's (DEF) 18. Other:_ ________________ 18. Others...... _________________________

INORSANIC ANALYSIS REQUESTED. ; . ■ (circle tests) * '' " .___ 1. Color 5009*58020 Acidity 39. Aluminum t Pott Im 2. Turbidity 21. Alkalinity, as CaCOs 40. Antimony / 7 /, 60. I elenium/7 3. pH' ’ " - 22. Bromide 41. Arsenic 61. Silver * * f 6 4. Conductivity 23. Bromate/Chlorate/Chlorite f 42. Barium 62. Sodium 43 Beryllium 5. 6. Corrosivity (temp: BOD (5 day) C) 24 Chloride 25 Cyanide 26. Fluoride 44, Boron 45.Cadmium 63. Thallium 64. Vanadium 65,Zinc 4 7. Soluble BOD (5 day) 8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOs '46. Calcium, as CaCO3 cr.............. (47Calcium, Ca*2 9. Chemical Oxygen Demand 110, Dis olved Oxvaen . 28. Nitrogen, Ammonia as N :9 Pno ;< , r SO Nitou* N:h .) H N 148.Chromium, Total . ■ . ;>=>■ ’ fn .1 66. Metals/CN / Volatlr 11. Total Organic Carbon bb.domi viclitile 12. Total Organic Halides. 31. Nitrogen, Total Kjeldahl as N 50.Cobalt f l potldkt" ’f.| ■ • 32. Oil an Grease /51.Copper : Solids, Percent (%) f4. Solids, Settleabie 33. Phenol '— 53.Lead 34. Phosphorus Total as P Ba ron 70. Disk Deliverables

TCLP "4 54 Magnesium 71 TCLP-Metals 35. Phosphorus, Ortho as P 72. TCLP-Pesticides 17. Solids, Total Dissolved 36. Sulfates ----- 55 Manganese 7 . ‘ou tduo T M1O-20 i 28 UV. .1 | 57 Mob Ii : haatyepnt i " C 6. 1Q215 I N

NYC-WTC_000026208