Chain of custody form, Westchester County Labs, undated

NYC 9/11 Public Portal Document *200179 y*pso*mprr2 nwrar *mrurepazgocin. XFM.MWP

JUI ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914) 593-5575 NYS-ELAP No. 10108 _________________________________ . Form A-70 (rev. 1/96) ’ Wample Type (circle one): 1546, (9761 c is ,*40,74 70 • 1) Potable 3. Non-Potable Treated Bottle #‘s:C • 5, Y ISC $188 $021 $177 f 2. Non-Potable 4. Other________________ - Chain of Custody? yes no Time/Date Collected: 1/302col _ -= Comments: Collected BvI.KBANBO Agency Code:. . PWS #: Source ID: Type Descriptor:. Collected From: . Bill to. Location’s/Individual’s Name be-* - Name/Company Street.......... .. ....................................... Street__________ City/St/Zip________________________ City/St/Zip______ Identification of Source________________ >-LA2A 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 8. PCB as Decachlorobiphenyl (508A) 8. Other Pesticides (SM-18/6630) 3Other: 9. Herbicides (515) 9. Petroleum Hydrocarbon Scan (310-13) (10. Pesticides (525) 10. Glycols in Water Refrigerated? yes no 11. Carbamate Pesticides (531) 11. Acid Extractables (625/8270) 12. Glyphosate (547) 12. Base Neutral Extractables (625/8270) Chionnated?: .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) 16. Pesticides (DEF) Total Chlorine Res: mg/lt. .17 Petroleum/Hydrocarbon Scan (310-13) 17. PCB’s (Arochlors) (DEF) :4 pH. i " ■

INORGANIC ANALYSES REQUESTED SLabil: (circle tests) 1, Color e .$ 20. Acidity 1& 39. Aluminum 1 uY’ o59.SPotassium 2. Turbidity | s tallply, as CaCOs 40. Antimony 60. Selenium 3. pH 41. Arsenic 61. Silver 4. Conductivity 2: i Bromate/Chlorate/Chlorite 42. Barium 62. Sodium 5. Corrosivity (temp: °C) 2: Caloride 43. Beryllium 63. Thallium 6. BOD (5 day) 39. 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*8 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 -14. Solids, Settleable 33. Phenol 52. Iron TCLP C Solids. Suspended 34. Phosphorus. Total as P 53. Lead 71.TCLP-Metals 5 "6. 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 me 58. Nickel

NYC-WTC_000026949