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Chain of custody form, Westchester County Labs

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Chain of custody record for samples submitted to the Westchester County Department of Labs and Research.

NYC-WTC_000072443–000072450

Folder label: “25457

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NYC 9/11 Public Portal Document ...A,..,.

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM sster r •#0ate Set: Dv.com WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914) 593-5575 z iff ? .i H NYS-ELAP No. 10108 Form A-70 (rev.1/96)

Sample Type (circle one): I'. Pota^le ;3. Non Potable Treated Bowe 2.NQi$'Potable 4. Other__________________________ Chain of Custody?___ yes no Tirrie/Date.i^lected: Comments: C^Hecf^d ^7^ Agency Code: PWS #:______ Source ID: Type Descriptor. ^dlecte^ From':; Bill to; E ^’^opation's/lndividual’s N^e. A/a/ Name/Company Street________ ; City/^ip - City/St/Zip " 7* V•

Identification of . Phoned Fax#:'' Collection Point- Zb cn I'CACH.'BI?^t^W ^Check#:? ^YgXXmoijn^ ‘

BACTERIOLOGIC^^SltsiS ORGANIC POTABLE ANALYSIS Lab#:________ ' • ■ Lab#: -n < I ' (circle tests) 1 . Heterotrophip l^tB. . 1. Trihalomethanes (524) : , 1.-Purgeable Halocarbons‘ (624/8260) D Count (hemodialj^fs’& all others) ^^TD/olatile Halocarbons (524) 2. Purgeable Aromatics (624/8260) i. 2. Coliform P/A^pui^ si^liOs) 13. Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624) 3. Coliform MPf^ (pqv w^, raw, stp) /t: Total Trihalomethane Potential (510) 4. Phthalates (625/8270) 4. Fecal Coliforrn (a/V^rfiples) 5. Microextractables (504) 5. Organochlorine Pesticides,(608/8081) I. Microscopic 6. Pesticides (507) 6. PCB’s (Arochlors) (608/8081)

?'Microscopic 8. Other: /TV Pesticides/PCB screen (508) 8. PCB as Decachlorobiphenyl (508A) 9^ Herbicides (515) 7. Methoprene (616) 8. Herbicides (EPAI 978/8151) 9. Pesticides (SMI8/6630) * cS

10. Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13) Refrigerated? yes no Tf 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) GC/MS Semivolatile Unknown Scan ’“D Total Chlorine Res: mg/L 15. Haloacetic Acids (552) 15. Purgeable Halocarbons (DEF) 16. Pesticides (SMI8/6630) 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. /'cidity 39;Alun^num ' 59. Potassium 2. Turbidity 21. Alkalinity, as CaCOa 40. Antirnony 60. Selenium { 3. pH 22. Bromide 41. Arsenic 61. Silver 4. .Conductivity 23. Bromate/Chlorate/Chlorite 42. Barium 62. Sodium 5; Cgrro^ity^temp; >------- ®C) 24. Chloride 43. Beryllium 63. Thallium ^ 6. BOD(5d^;^aE 25. Cyanide 44. Boron 64. Vanadium 1 7. Soluble. BOD (^d^ / 26. Fluoride 45. Cadmium 65. Zinc 8. Carbonaceous BOB''‘(^day) 27. Hardness, Total as CaCOa 46. Calcium, as CaCOs GLP 9. Chemical Oxygen Deitiarid -4 ■ 28. Nitrogen, Ammonia as N 47. Calcium, Ca*^ 66. Metals/CN 5t 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. Pesticides/PCB’s lolids, Percent (%) 32. Oil an Grease 51. Copper 70. Disk Deliverables iolids, Settleable 33. Phenol 52. Iron TCLP 15. Solids, Suspended 34. Phosphorus Total as P 53.Lead 71 TCLP-Metais 16. 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

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NYC-WTC_000070652 · Box DEP Box 61

Record documenting the chain of custody for samples submitted to the Westchester County Department of Labs and Research.

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