Chain of custody record, Westchester County Labs, Oct 2001

NYC 9/11 Public Portal Document

ACChl ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM jester mvcom WESTCHESTER COUNTY LABORATORIES AND RESEARCH o 2 Dana Road, Valhalla, New York 10595 u (914)231-1620 Fax (914) 231-1772 ' - NYS-ELApklo/Wlba Time/Date Set: Form A-70 (revfl0/01)

Sample Type (circle one): '1.Pota^,> 3. Non Potable Treated Bottle #’s: 2. Non Potable -4. Other____________ Chain of Custody? Yes No Time/Date Collected: Y ,• Comments; Collected By: • Agency Code: PWS #:________ Source ID; l_Type^Descriptor." 1 Collected From; Bill to; .' ■J

Location’s/lndividual’s Name Name/Company Street_________________ Street_________ City/St/Zip______________ City/St/Zip Identification of Source Phone#:_______ : Collection Point I CA,CH. Bl?

BACTERIOLOGICAL ANALYSIS JLab#: Lab#:____________ _ _________ . . U- I ORGAN,CNONPOTABLE,SOL,DANfe,S^: ORGANIC POTABLE ANALYSIS __ Heterotrophic.Plate Count (hemodialysis & all others) _Trihalomethanes (524) . __ Purgeab(e Halocarboris<(624/8266)''- Y;;v; __ Volatile Halocarbons (524) , Purgeabie Aromatics'(624/8260f)Y.Y __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) __ Volatile Aromatics (524) Acroleirv & Aci^6hitrile ;(826bj; __ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) __ . Orgariochlorine Pesticides ■(608^08i) YiY^> __ Microscopic __ Microextractables (504) PCB's (Arochlors) Y608/8081)Yy ':^‘Y^Y'^ / __ Macroscopic __ Pesticides/PCB screen (508) _ Herbicides (SMI8/6630,8151) _ 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 ExtractaWes;(625^270) Chlorinated:?yes___ no "_ Glyphosate (547) __ Base Neutral Extractables (625/8270) ' ' Diquat (549) .-''gC/MS Unknown Scan - J'? ; ' Y ' Y; Free Chlorine Res:mg/L __ Chlorination Disinfection Byproducts (551) _ Phthalates (606MS)- Total Chlorine Res:mg/L __ Haloacetic Acids (552) __ Other:______ _ _ Other Pesticides (SMI8/6630) •t; pH ___________ _UCMR List1 RADIOCHEMICAL ANALYSIS _ MtBE Only (524) __ Radon __ Other____________________

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

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