Chain of custody form, Westchester County Lab, Sep 2001

NYC 9/11 Public Portal Document 1/ ...... -........... i Y

AMENTAL SERVICES SAMPLE SUBMISSION FORM ENVIROI WESTCHESTER COUNTY LABORATORIES AND RESEARCH L 58. ii 2 Dana Road, Valhalla, New York 10595 (914) 593-5575 NYS-ELAP No. 10108 Time/Date Set: £* Form A-70 (rev. 1/96)

Sample Type (circle one): # g s $ 3, 8 SS 7, 8sS S. 6 S6 2 - C 4$20 j Bottle #‘s: (233,3493,9638 0248,8563, BSS/ (Potable 3. Non Potable Treated 2. Non Potable 4. Other___ ________________________ Chain of Custody? yes no ‘ Time/Date Collected: 4/21300/______% < c .. P Comments: Collected By: “A(7// te CAo Agency Code:________ _ Source ID: .Type Descriptor Collected From: / g. Bill to: Location’s/Individual’s Name Ail/yiew Csevory Name/Company _ Street____________ Street_______ _ City/St/Zip_________ _ Identification of Source Phone#:______ Fax# Collection Point 913 CA,CH, BI? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS Lab#:___________________ L Lab#:______________________ (circle tests) % (circle tests) 1. Heterotrophic Plate 1. Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260) Count (hemodialysis & all others) 2. Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260) 2. Coliform P/A (public supplies) 4 3 Volatile Aromatics (524) . — 3. Acrolein & Acrylonitrile (624) 3. Coliform MPN (priv well, raw, stp) 4. Total Trihalomethane Potential (510) 4. Phthalates (625/8270) 4. Fecal Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8081) 5. Microscopic 6. Pesticides (507) 6. PCB’s (Arochlors) (608/8081) 6. Macroscopic r7Pesticides/PCB screen (508) 7. Methoprene (616)

@r— Refrigerated? yes no 8. PCB as Decachlorobiphenyl (508A) 9. Herbicides (515) 10 Pesticides (525) 8. Herbicides (EPA1978/8151) 9. Pesticides (SMI8/6630) 10. Petroleum Hydrocarbon Scan (310-13) 1. Carbamate Pesticides (531) 11. Glycols Chlorinated:? yes no . 12. Glyphosate (547) 12. Acid Extractables (625/8270) a ■ 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, ' 3 15. Haloacetic Acids (552) 15. Purgeable Halocarbons (DEF) 16. Pesticides (SM18/6630) 16. Purgeable Aromatics (DEF) ------- 17. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB's (DEF) 15** 1 . ’.: * 4 G• 18. Often. 18. Other. _____________ _____ : INORGANIC ANALYSIS REQUESTED - Lab#: (circle tests) 20. Acidity -5255 39. Aluminum AM <59. Potassium 1. Color 2. Turbidity 21. Alkalinity, as CaCOs 40. Antimony 60. Selenium 3. pH 22. Bromide 41. Arsenic 61. Silver 4. Conductivity - 23. Bromate/Chlorate/Chlorite 42. Barium 62. Sodium 5. Corrosivity (temp:__ °C) • 24. Chloride 43. Beryllium 63. Thallium 6. BOD (5 day) 25. Cyanide 44. Boron 64. Vanadium 7. Soluble BOD (5 day) 26. Fluoride 45. Cadmium 65. Zinc_________ 8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOs 46. Calcium, as CaCOs CLP 9. Chemical Oxygen Demand 28. Nitrogen, Ammonia as N 47. Calcium, Ca*2 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-vlolatlles 12. Total Organic Halides 31. Nitrogen, Total Kjeldahl as N 50. Cobalt 69. Pesticides/PCB’s 13. Solids, Percent (%) 32. Oil an Grease 51. Copper 70. Disk Deliverables 33. Phenol 52. Iron 6 Solids, Settleable TCLP Solids, Suspended 34. Phosphorus Total as P 53.Lead 54 Magnesium 71 .TCLP-Metals Solids, Total 35. Phosphorus, Ortho as P 55 Manganese 72.TCLP-Pesticldes 17. Solids, Total Dissolved 36. Sulfates 56. Mercury 73.TCLP-Herblcides 37. Surfactants 18. Solids, Total Volatile 19. Other ___________ 38. UV254 57 Molybdenum 74. TCLP-Volatiles 75.TCLP-BNA’s 58. Nickel

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