Chain of custody form, Sep 2001

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM Wotchsto sgovcom WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla. New York 10595 2(914)593-5575 NYS-ELAP No. 10108 Time/Date Set: Form A-70 (rev.1/96) Sple Type (circle one): * 1c- 16 30 2lL, 22/2,80/3,0375 1. Potable 3. Non Potable Treated Bottle #‘s: /] -F6,5S,PBF6.8‘ 2. Non Potable 4. Other Chain of Custody?___ yes..... ... no Time/Date Collected: 000 9 IA1 Comments:_ Collected By: i7t.2s . Agency Code: PWS ________ _ Source ID:____ ___ Type Descriptor: Collected From: Bill to: i l f f ti M, y.f Location's/Individual ’s Name T-Ti /‘ / i / Name/Company.. Street — _ -■ 1__ AaL/........ LZAe Street_________ City/St/Zip___ L.LA___ 4_SS___ City/St/Zip Identification of Source_ ___________ ._____ Phone#: .. .._..... . Fax#: Collection Point 77 CA,CH, Bi? J..... Check#: ... Amounts.. —// BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE AN ALY bio ORG/N*( NONP165 ANALYAS Lab#:_________________________ Lab#:_______ __ =__ ___ — _ (circle tests) (circle tests) / / € 7 / / 1. Heterotrophic Plate 1. Trihalomethanes (524)' 1. Purgeable Halocarbons (624/8260) 2 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) 'A 3. Coliform MPN (privwell, raw.stp) 4. Total Trihalomethane Potential (510) 6-4 Phthalates (625/8270) 4. Fecal Coliform (all samples) b. Mictoextractaoies (004) 5. Organochlorine Pesticides (608/8081) — Microscopic . Macroscopic 116. Pesticides (507) Ta .-7.Methoprene(616)a1ys 6. PCB’s (Arochlors) (608/8081) g‘ Sher: .2 -8, Herbicides (EPA1978/8151)_ ( 7 X 1 f !■ -.-.-r ■. i . : 2

-9, He B B ! rbi c i des (515) . i lol * . a 9. Pesticides (SM 18/6630) Refrigerated? yos___ no (10--Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13)"

Chlorinated:? yes__ . no 11. Carbamate Pesticides (531) 12. Glyphosate (547) 11. Glycols 12. Acid Extractables (625/8270) —9 13. Diquat (549) 13. Base Neutral Extractables (625/8270) Free Chlorine Res: .... mg/L 14. Chlorination Disinfection Byproducts (551) 14. GC/MS Semivolatile Unknown Scan total Chlorine Res mg/L 15. Haloacetic Acids (552) 15. Purgeable Halocarbons (DEF) 16. Pesticides (SM18/6630) 16. Purgeable Aromatics (DEF). pH . 17. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB’s (DEF) ; 18. Other:____ ________________ 18. Other:__ __ _____________ '

INORGAMC Ar Al. v SIS RE QUESTE D - I ■ (circle tests) Color ntaahag" ,1.2. Turbidity : 20. Acidity 21. Alkalinity, as CaCOa ) 39. Aluminum | 40. Antimony hus - k (l ‘otassium 760. elenium /

3. pH 22. Bromide 41. Arsenic i 61. liiver ! 4. Conductivity 23. Bromate/Chlorate/Chlorite 24, Chloride _ C 42. Barium 43/Beryilium 62. odium hallium s 5. Corrosivity (temp:...........°C) i 63. 6. BOD (5 day) 7. Soluble BOD (5 day) 8. Carbonaceous BOD (5 day) 26, Fluoride_ 25. Cyanide

27. Hardness, Total as CaCO3 44. Boron 45, Cadmium 46 Calcium, as CaCOa 34. ■ 65/ Zinc V CLP_ n: . fat-:

9 Chemical Oxygen Demand 28. Nitrogen. Ammonia as N :47.Calcium, Ca*2 66. Metals/CN I 29. Nitrogen, Nitrate as N i 48.Chromium, Total 10. Dissolved Oxygen 67. Volatiles 30. Nitrogen, Nitrite as N 49. Chromium, Hexavalent 11. Total Organic Carbon 68. Semi-violatiles (50.Cobalt 12.3. Total Organic Halides - Solids, Percent (%) 31. Nitrogen, Total Kjeldahl as N 32. 011 an Grease M 151.opper 69. Pesticides/PCB’s 70. Disk Deliverables 1 33. Phenol iftg — 52. Iron TCLP 14. Solids, Settleable ■■Solids, Suspended Lead a — 5453Magnesium 34. Phosphorus Total as P 71TCLP-Metals to; Solids, Total 136.37. SulSurfactants fates __ woalkeg 10 5556. Manganese 35. Phosphorus, Ortho as P 72.TCLP-Pesticides TCLP-Herbicides— 73.74.TCLP-Volatiles_ 18. Sol i d s, Tot a l Volatile- 17. Solids, Total Dissolved Mercury a 19.other— 38.UV254d 157 Molybdenum 158.Nickela 75.TCLP-BNAsI Md NYC-WTC_000026210