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Chain of custody form, Westchester County Lab, Sep 2001

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Record documenting sample transfer and custody for environmental testing at the Westchester County Department of Labs & Research.

NYC-WTC_000026432–000026446

Folder label: “23318

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NYC 9/11 Public Portal Document

ster ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM com WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 15 (914) 593-5575 NYS-ELAP No. 10108 Time/Date Set: Form A-70 (rev. 1/96)

ample Type (circle one): P,PF%, 228,229,250 1.Potable 3. Non Potable Treated Bottle #‘s: S70,9072,(SOS,036S,n002, P 2. Non Potable 4. Other _ __________________ Chain of Custody? yes no Time/Date Collected: 424/200 0836 Comments: Collected By: S, Brww - Agency Code: PWS#:_______ Source ID: .Type Descriptor Collected From: — > Bill to: Location’s/ndividual’s Name D —____________ Name/Company Street______ _ ______________________________ Street________ CIty/St/Zip.___________________________________ CIty/St/Zip Identification of Source__________________________ Phone#: _ _____ Fax# Collection Point_ 2-2DSO_________ CA,CH, BI? . Check#: Amounts.

BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS

(circle ------ Lab# . . C A1 99 Lab#:___________________ _ (circle tests) tests) 1. Heterotrophic Plate 1. Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260) Count (hemodialysis & all others) 2. Coliform P/A (public supplies) 2 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) 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151) oner______________ 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. Acid 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: 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.

INORGANIC ANALYSIS REQUESTED - Lab#: (circle tests) 1. Color 20. Acidity 39. Aluminum 59. Potassium 2. Turbidity 21. Alkalinity, as CaCOs 40. Antimony 60. Selenium 22. Bromide 41. Arsenic 61. Silver .Ss 3. pH 4. Conductivity 23. Bromate/Chlorate/Chlorite 42. Barium 62. Sodium UJ 5. Corrosivity (temp:. °C) 24. Chloride 43. Beryllium 44. Boron 63. Thallium 6. BOD (5 day) 25. Cyanide 64. Vanadium 7. Soluble BOD (5 day) 26. Fluoride 45. Cadmium 65. Zinc C 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 S 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.Seml-violatlles 3 C 12. Total Organic Halides 31. Nitrogen, Total Kjeldahl as N 50.Cobalt 69.Pesticides/PCB’s 13. Solids, Percent (%) 14. Solids, Settleable Colids, Suspended 32. Oil an Grease 33. Phenol 34. Phosphorus Total as P 51. Copper 52. Iron 53.Lead 70. Disk Deliverables TCLP t 16.Solids, Total 35. Phosphorus, Ortho as P 54 Magnesium 71 .TCLP-Metals 72.TCLP-Pesticides 03 17. Solids, Total Dissolved 36. Sulfates 55 Manganese 73. TCLP-Herbicides 18. Solids, Total Volatile 37. Surfactants 56. Mercury 57 Molybdenum 74. TCLP-Volatiles 19. Other______________ _ 38. UV254 75.TCLP-BNA’S 58. Nickel

NYC-WTC_000026436

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