Chain of custody form, Westchester County Lab, Sep 2001

NYC 9/11 Public Portal Document - -................ .... ........... 1-=*=*===

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ter WESTCHESTER COUNTY LABORATORIES AND RESEARCH com 2 Dana Road, Valhalla, New York 10595 (914) 593-5575 I NYS-ELAP No. 10108 GerDate Set: Form A-70 (rev.1/96)

Sample Type (circle one): ( 1. Potable 3. Non Potable Treated Bottle #‘s: 1 ) 7:2 2215 2. Non Potable 4. Other _____ Chain of Custody? yes no Time/Date Collected: 4/20 /2 co / Comments: Collected By: B.Ou Agency Code: _ Source ID: .Type Descriptor Collected From: Bill to: Location’s/Individual’s Name 3k Name/Company _ Street__________________ Street________ CIty/St/Zip_______________ City/St/Zip Identification of Source M-MPtAB# Phone#:______ Fax#: Collection Point 265S0 2 8 S2 6 CA,CH, Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS Lab#: % Lab#:____________________ (circle tests) (circle tests) 1. Heterotrophic Plate 1. Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260) Count (hemodialysis & all others) 2. Coliform P/A (public supplies) A ar Volatile Halocarbons (524) Volatile Aromatics (524) 2. Purgeable Aromatics (624/8260) 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 (7 Pesticides/PCB screen (508) 7. Methoprene (616) a. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151) 8. Other_______________ 9. Herbicides (515) 9. Pesticides (SM18/6630) “10 Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13) Refrigerated? yes no 11. Carbamate Pesticides (531) 11. Glycols Chlorinated:? yes no 12. Glyphosate (547) 12. Add Extractables (625/8270) 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: __ img/l J115. Haloacetic Acids (552). 15. Purgeable Halocarbons (DEF) *e* 116. Pesticides (SM18/6630).4, 16. Purgeable Aromatics (DEF) pH .N 4 . 17. Petroleum/HydrocarbonScan (310-13) 17. Pesticides/PCB’s (DEF) _ ““aC===*0r======= INORGANIC ANALYSIS REQUESTED - Lab* / Z( | h - 1. Color 20. Acidity ■ 39. Aluminum 59. Potassium 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 CaCO3 46.Caldum, as CaCOs CLP 9. Chemical Oxygen Demand 28. Nitrogen, Ammonia as N 47.Caldum, 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-violatiles 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 d Solids, Settleable 33. Phenol 52. Iron VSolids, Suspended 34. Phosphorus Total as P 4.Lead TCLP 54 Magnesium 71 .TCLP-Metals 16. Solids, Total 35. Phosphorus, Ortho as P 36. Sulfates 55 Manganese 72.TCLP-Pesticldes 17. Solids, Total Dissolved 73. TCLP-Herbiddes 18. Solids, Total Volatile 37. Surfactants 56. Mercury 57 Molyodenum 74. TCLP-Volatlles 19. Other________________ 38. UV254 75.TCLP-BNA's 58. Nickel

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