Chain of custody record, Westchester County Labs, Oct 2001

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ter WESTCHESTER COUNTY LABORATORIES AND RESEARCH :com o 4 2 Dana Road, Valhalla, New York 10595 o (914)231-1620 Fax (914) 231-1772 lx NYS-ELAPNo. 10108 Time/Date Set: Form A-70 (rev. 10/01)

Sample Type (circle one): r 'Y Yz 1. Potable 3. Non Potable Treated Bottle #'s; r 2. Non Potable 4. Other ________ Chain of Custody?. Yes No Time/Date Collected: Comments: Collected By: Agency Code: PWS #:________ Source ID: Type Descriptor: ; Collected From: Bill to: Location’s/lndividual’s Name 'tf I F-F L. Name/Company r.'

Street_________________ Street _ _______ City/St/Zip______________ City/St/Zip Identification of Source Phone#:; .Fax#: Collection Point I CA,CH. Bl? Check#: __ Amount$

BACTERIOLOGICAL ANALYSIS 't Lab#:_______________________ ORGANIC POTABLE ANALYSI^ ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count __ ■ Purgeable Halocarbons ’ (624/8260) -'?"; (hemodialysis & all others) _Trihalomethanes (524) _ Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) ' __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) __ Volatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) ' __ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides '(608/8081) __ Microscopic __ Microextractables (504) _ PCB’s (Arochlors) (608/8081) __ Macroscopic __ Pesticides/PCB screen (508) _ Herbicides (SM18/6630.8151) ■■ .

_ API __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SMI8/6630) __ Other:_____________________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) _ __ Pesticides (525) __ Glycols in Water Refrigerated?yes___ no __ Carbamate Pesticides (531) _ Acid Extractables (625/8270) Chlorinated:?yes no __ Glyphosate (547) __ Base Neutral Extractables (625/8270) .. __ Diquat (549) Y. GC/MS Unknown Scan ‘a Free Chlorine Res:mg/L __ Chlorination Disinfection Byproducts (551) _ Phthalates (606MS) Total Chlorine Res:mg/L _ Haloacetic Acids (552) __ Other:_____________________ _ _Other Pesticides (SMI8/6630) pH ___________ _UCMRList1 RADIOCHEMICAL ANALYSIS _MtBE Only (524) __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#; __ Color __ Acidity __ Aluminum __ Potassium _ Turbidity __ Alkalinity __ Antimony _ pH __ Bromide __ Arsenic __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium j __ Corrosivity (temp;. .°C) __ Chloride >.__ Beryllium __ Thallium’ _ BOD (5 day) __ Cyanide __ Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ cadmium __ Zinc __ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOs __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*^ CLE _Metals/CN __ Dissolved Oxygen __ Nitrogen, Nitrate as N __ Chromium, Total __ Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Semi-violatiles __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N __ Cobalt __ Pesticides/PCB’s __ Solids, Percent (%) __ Oil and Grease __ Copper __ Solids, Settleable __ Phenol __ Iron TCLP __ Solids, Suspended __ Phosphorus Total as P __ Lead _TCLP-Metals __ Solids, Total __ Phosphorus, Ortho as P __ Magnesium __ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates __ Manganese _TCLP-Herbicides __ Solids, Total Volatile __ Surfactants __ Mercury _ TCLP-Volatiles __ Other:__________________ _ UV254 __ Molybdenum _ TCLP-BNA's _ Nickel

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