Chain of custody form, Westchester County Labs, undated

NYC 9/11 Public Portal Document 22091295 \ i

> ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914) 593-5575 /NYS-ELAP No. 10108 ge/Date Set: _____________________ Form A-70 (rev. 1/96) $u 9519*2. — "ample Type (circle one): 1. Potable 3. Non-Potable Treated . 30 2191 845 /as /S% Bottle #'s:______________ 2. Non-Potable 4. Other ________________ _ Chain of Custody?____ yes no Time/Date Collected: 08/zoof ___ US1 Comments:____________ Collected By:. ToU, Agency Code: _ Source ID: Type Descriptor:. Collected From: Bill to: Location’s/Individual’s Name. OLAS Name/Company. Street________________ Street_______ City/St/Zip_____________ City/St/Zip Identification of Source____ L&IA# Phone#: _Fax # Collection Point. 425Q 1 29500 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) 30 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-1 8/6640; 8151) 7. API ' -8. PCB as Decachlorobiphenyl (508A) 8. Other Pesticides (SM-18/6630) __ 9. Herbicides (515) 9. Petroleum Hydrocarbon Scan (310-13) (10. Pesticides (525) 10. Glycols in Water Refrigerated? yes no 444. Carbamate Pesticides (531) 11. Acid Extractables (625/8270) 12. Glyphosate (547) 12. Base Neutral Extractables (625/8270) ______________ yes no 13. Diquat (549) 13. GC/MS Unknown Scan 14. Chlorination Disinfection Byproducts (551) 14. Purgeable Halocarbons (DEF) Free Chlorine Res:. mg/L 15. Haloacetic Acids (552) 15. Purgeable Aromatics (DEF) 16. Other Pesticides (SM-18/6630) ' 16. Pesticides (DEF) Total Chlorine Res: mg/L 17. Petroleum/Hydrocarbon Scan (310-13) : 17. PCB’s (Arochlors) (DEF)

pH

INORGANIC ANALYSES REQUESTED - Lab#:. (circle tests) 1. 2. Color T urbidity 20. Acidity 21. Alkalinity, as CaCOs 257Maas..39. Aluminum ’ 40. Antimony 59. Potassium 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 TCLP 0 Solids, Settleable 33. Phenol 52. Iron Solids. Suspended 34. Phosphorus. Total as P 53. 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_000026946