Chain of custody form, Westchester County Labs, undated

NYC 9/11 Public Portal Document ***" ■ T................. . '• ■'' '

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III ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH !Y 2 Dana Road, Valhalla, New York 10595 Utestchestertounty NYS-ELAP No. 10108. (914)593-5575 /Date Set: _____ iple Type (circle one): oveo ■ 44 83,6y50, sac, e org,90»3/,0 G 2,5 20su ,89,89 so > Seus 1. Potable 3. Non-Potable Treated Bottle #’s:__________________________________ _ 2. Non-Potable 4. Other_____________ Chain of Custody? .yes .no Time/Date _ __________________ :________ /454 Comments: Collected By: M-(ACoB .Agency Code: PWS #:_________ Source ID:. Type Descriptor: Collected From: Bill to: Location’s/Individual’s Name_ L, se N Y Name/Company Street _________________ Street__________ _ City/St/Zip______ Identification of Source Pz- „** Phone#:, Fax#: Collection Point CA,CH, BI?, Check#: Amounts.

BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES Lab#:____________________ 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) 3. Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624) 3. Coliform MPN (priv well, raw, stp) 4. Total Trihalomethane Potential (510) 4. Phthalates (606/8060) 4. Fecal Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8080) 5. Microscopic 6. Pesticides (507) 6. PCB's (Arochlors) (608/8080) 6. Macroscopic (7.) Pesticides/PCB screen (508) 7. Herbicides (SM-18/6640; 8151) 7. API 87 PCB as Decachlorobiphenyl (508A) 8. Other Pesticides (SM-18/6630) Other: 9. Herbicides (515) 9. Petroleum Hydrocarbon Scan (310-13) (10./Pesticides (525) . 10. Glycols in Water Hefrigerated? yes. .no 11. Carbamate Pesticides (531) 11. Acid Extractables (625/8270) 12. Glyphosate (547) 12. Base Neutral Extractables (625/8270) Chlorinated?: yes. .no 13. Diquat (549) 13. GC/MS Unknown Scan 14. Chlorination Disinfection Byproducts (551)| 14. Purgeable Halocarbons (DEF) Free Chionne Res:. mg/L 15. Haloacetic Acids (552) 15. Purgeable Aromatics (DEF) 16. Other Pesticides (SM-18/6630) m 18. Pesticides (DEF) Total Chlorine Res: mg/L 17. Petroleum/HydrocarboniScan (310-13) 17. PCB’s (Arochlors) (DEF)

pH. INORGANIC ANALYSES REQUESTED - Lab#:. (circle tests) * 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 I 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-volatiles * 12. Total Organic Halides 31. Nitrogen, Total Kjeldahl as N 50. Cobalt 69. Pesticides/PCB’s 13. Solids, Percent (%) 32. Oil and Grease 51. Copper 70. Disk Deliverables Solids, Settleable 33. Phenol 52. Iron TCLP Solids. Suspended 34. Phosphorus. Total as P S3. Lead 71. TCLP-Metals 1 Solids, Total 35. Phosphorus, Ortho as P 54. Magnesium 72. TCLP-Pesticides 17. Solids, Total Dissolved 36. Sulfates 55. Manganese 73. TCLP-Herbicides 18. Solids. Total Volatile 37. Surfactants 56. Mercury 74. TCLP-Volatiles 19. Other:_____________ 38. UV254 57. Molybdenum 75. TCLP-BNA’s 58. Nickel

NYC-WTC_000026954