Chain of custody form, Westchester County Lab, Sep 2001

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7 ’ / ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM 4 est ster vcom WESTCHESTER COUNTY LABORATORIES AND RESEARCH UE 2 Dana Road, Valhalla, New York 10595 (914) 593-5575 . ' NYS-ELAP No. 10108 d/Date Set: • Form A-70 (rev. 1/96)

Sample Type (circle one): ? 5 7 ? C *‘ " ‘7 (1. Potable 3. Non Potable Treated Bottle #s:0=27 006 2. Non Potable 4. Other________________________ Chain of Custody? yes no Time/Date Collected: 9/ _ ______________ __ Comments: Collected By: D, So eko Agency Code: PWS#:_______ Source ID: .Type Descriptor Collected From: Bill to: Location’s/Individual’s Name 61 Name/Company _ 7 Street________________ Street________ CIty/St/Zip_____________ City/St/ZIp Identification of Source ______ ,P9-DP(A6# Phone#:______ Fax#: Collection Point 5/250 28549 CA,CH, Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS Lab#: t 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) C. 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, Macroscopic ___ (o Pesticides (507) Pesticides/PCB screen (508) 8. PCB as Decachlorobiphenyl (508A) 9. Herbicides (515) 6. PCB’s (Arochlors) (608/8081) 7. Methoprene (616) 8. Herbicides (EPA1978/8151) 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. Acid Extractables (625/8270) 13. Diquat (549) : ,13. Base Neutral Extractables (625/8270) A. Free Chlorine Res:__ _ mg/L 14. Chlorination Disinfection Byproducts (551).14. GC/MS Semivolatile Unknown Scan s « Haloacetic Acids (55P! 15. HalnacatinAciris (552) jit ,15. Purgeable Halocarbons (DEF) Total Chlorine Res: _ mg/L 16. Pesticides (SM18/6630)444s $5316. Purgeable Aromatics (DBF) 10 poehcdee cAsg/o0 5 pH 3. INORGANIC ANALYSIS REQUESTED - Lab#: 232 7hwh/ 17. Petroleum/Hydrocarbon Scan (310-13)3041417;Pesticides/PCB‘s (DEF) 18. Other ) -1/21Phr— , —------ --- /-50 (circle tests) 1. Color 20. Asidity A 23,35. Almindm— -9 21. Alkalinity, as CaCOs .0* . 40. Antimony 59. Potassium 60. Selenium 2. Turbidity 3. pH 22. Bromide 41. Arsenic oo 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-violatiles 12. Total Organic Halides 31. Nitrogen, Total Kjeldahl as N 50.Cobalt 69.Pestlcides/PCB’s 13. Solids, Percent (%) 32. Oil an Grease 51. Copper 70. Disk Deliverables 2 Solids, Settleable 33. Phenol 52. Iron 53.Lead TCLP (Solids, Suspended 34. Phosphorus Total as P 54 Magnesium 71 TCLP-Metals TK. Solids, Total 35. Phosphorus, Ortho as P 55 Manganese 72.TCLP-Pesticides 17. Solids, Total Dissolved 36. Sulfates 56. Mercury 73.TCLP-Herblcides 18. Solids, Total Volatile 37. Surfactants d 38. UV254 57 Molyodenum' 74. TCLP-Volatiles 19. Other________________ 75.TCLP-BNAs 58. Nickel , •

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