Chain of custody record for Westchester County Department

NYC 9/11 Public Portal Document I

ACCO.B. ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM lester RDvcom WESTCHESTER COUNTY LABORATORIES AND RESEARCH . 2 Dana Road, Valhalla, New York 10595 (914) 231-1620 Fax (914) 231-1772 NYS-ELAP No. 10108 Time/Date Set: Form A-70 (rev.10/01)

S^QTiple Type (circle one): >7 7?7 / 1 ..Potable 3. Non Potable Treated Bottle #'s: . 2. Non Potable 4. Other Chain of Custody? Yes No ‘-^Time/Date Collected; .. //? 1/0 2-' Comments; Collected By: h": . Agency Code: PWS #:________ Source ID: Type Descriptor: Collected From: Bill to: Location’s/lndividual’s Name ^25^ Name/Company _ Street_________________ Street_________ City/St/Zip______________ City/St/Zip Identification of Source Phone#:_______ Fax#: Collection Point CA.CH, Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS Lab#:________________________________ Lab#:_______________________ U. / :) U ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/ SOLID ANALYSIS __ Heterotrophic Plate Count _Trihalomethanes (524) (hemodialysis & all others) __ Purgeable Halocarbons (624/8260) __ Coliform P/A (Public supplies) __ Volatile Haibcarbons (524) __ Purgeable Aromatics (624/8260) __ 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) _v^C/MS Unknown Scan 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 __ A:idity *^luminum __ Potassium __ Turbidity _ Alkalinity ^Antimony Selenium _ pH __ Bromide ^Arsenic JiBilver __ Conductivity __ Bromate/Chlorate/Chlorite Barium __ Sodium __ Corrosivity (temp:. .°C) __ Chloride Beryllium Thallium _ BOD (5 day) __ Cyanide __ Boron __ .Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium J<Zinc Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOs CLE __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*^ __ Dissolved Oxygen __ Nitrogen, Nitrate as N _ Metals/CN tZGhromium. Total __ Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Semi-violatiles __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N Ui Cobalt __ Pesticides/PCB’s __ Solids, Percent (%) ' , __ Oil and Grease , JC 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 Vplatile __ Surfactants JiZ Mercury _ TCLP-Volatiles ,. v _!<■ Other: /t.___________ _ UV254 u-Molybdenum jE Nickel TCLP-BNA’s _W__ NYC-WTC_000072906