Chain of custody form, Sep 2001

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM cst liston i { X.t * : ::j WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 W_(914)593-5575_ NYS-ELAP No. 10108 Time/Date Set: Form A-70 (rev. 1/96)

Sample Type (circle one): ' ' XA -■ / / AK/ taRTNyptve 589kaEkar Bottle #‘s: 12 277 / A ‘' i ,1. Potable J 3. Non Potable Treated 2.Non Potable 4. Other_____________ Chain of Custody?__ yes___ no da. Time/Date Collected:____ Y LIDL. . Comeners (alndibm Collected By: ________________ Agency Code: PWS #:___________ ' ■ ■ : ■ i: _Type Descriptor: Cull-tsi ! tons Bill to: Location’s/ndividual’s Name .... 4LDc t._. Name/Company___

A101 _A_ Street___ • Street City/St/ZipI 10770a / City/StZip_________ Identification of Source____ __________ Phone#: Fax#: Collection Point___ ______ ___ ___ ___ CA.CH, Bl? _ Check#: _ Amount__

BACTERIOLOGICAL ANALYSIS 0 ?GAN PDIABi r. AALYN% OPa, FC NONPOTA8S041 ANALYSIS Lab#:___________________ Lab#: $ /,7 Q (circle tests) (circle tests) 1. Heterotrophic Plate 1 Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260) Count (hemodialysis & all others) /2.olatile Halocarbons (524) 2. Purgeable Aromatics (624/8260) 2. Coliform P/A (public supplies) —3, Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624) 3. Coliform MPN (priv well, raw. stp) -4. Total Trihalomethane Potential (510) :4. Phthalates (625/8270) * Fecal Coliform (all samples) !>. Mrol x* . 5; -Organochlorine Pesticides (608/8081) ya6. Microscopic Macroscopic 2 6. Pesticides (507) T I 77Pesticides/PCB screen (508) • . * (Ao Hor 0 (0***) 7.. Methoprene (616) 7. 8 Hi 8, PCB as Decachlorobiphenyl (508A) . 9. Herbicides (515) 8. Herbicides (EPA1978/8151) 9. Pesticides (SM18/6630) 0) Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13) Refrigerated?____ yes ____ no

Chlorinated:? yes...... no 1. Carbamate Pesticides (531) 12. Glyphosate (547) 11, Glycols 0000/070 12. Acid Extractables (625/8270) 13. Diquat (549) 13. Baser Neutral Extractables (625/8270) Free Chlorine Res: __ mg/L 14. Chlorination Disinfection Byproducts (551) 14. GC/MS Semivolatile Unknown Scan 15. Haloacotic Acids (552) 15. Purgeable Halocarbons (DEF) Total Chlorine Res: ....... mg/L 16. Pesticides (SM18/6630) 16. Purgeable Aromatics (DEF) - ■ ■ 17. Petroleum/Hydrocarbon Scan (310-13) 118. Other - 17. Pesticides/PCB’s (DEF) 18. Other __ ___ ___ _____ :

INORGANIC ANAi ySIS REQUEST LD - 1 : • (circle tests) 1. Color ooaomtnthi 20. Acidity AMali. . * /39. Aluminum [ 40. Antimony ” $0 59. P otassium (,■>. Sole a 2. Turbidity 3.pH 22. Bromide 23. Btomate/Chlorate/Chlorite 41. Arsenic 42. Barium 61. Silver 62. Sodium 11 4. Conductivity 5. Corrosivity (temp: ... ... _°C) 24. Chloride , 43 Beryllium | 63. Thallium 44. Boron 6. BOD (5 day) 7. Soluble BOD (5 day) 25. Cyanide 26. Fluoride /45, Cadmium_ 5 64. Vanadium (65,‘Zinc 8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCO3 28. Nitrogen, Ammonia as N 46.Calcium, as CaCOs 47.Calcium, Ca+2 CLP- 1 9. Chemical Oxygen Demand 66. Metals/CN 10. Dissolved Oxygen 29. Nitrogen, Nitrate as N 48..Chromium, Total 67. Volatiles 11. Total Organic Carbon 30. Nitrogen, Nitrite as N 49. Chromium, Hexavalent 68. Semi-violatiles (50.Cobalr E Total Organic Halides 31. Nitrogen, Total Kjeldahl as N 69. Pesticides/PCB’s 51. Copper 33.Phenoln9 152.53.Leade Iron m ,3. Solids, Percent (%) 32. Oil an Grease 70. Disk Deliverables 14. Solids, Settleable TCLP Colids, Suspended 10. Solids, Total 34. Phosphorus Total as P I 54 Magnesium sain 35. Phosphorus, Ortho as P 71TCLP-Metals 17. Solids, Total Dissolved 18. Solids, Total Volatile 36.37. Sulfates Surfactants er 56. Mercury — Jmen 55 Manganese 72.TCLP-Pesticides 73. TCLP-Herbicides / iti 0 Vol iion 1» (Mb■ 4 38.UV254eee 58 Nickel i t ’ M "y Xa" A. n PNNAS

NYC-WTC_000026209