Chain of custody record with sampling and analysis fields

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ester Tovcom 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^76(rey.i 0/01)

Sample Type (circle one): /1. Potable 3. Non Potable Treated Bottle #'s: '-Z Non Potable 4. Other . G- > ' A.' Chain of Custody?___ Yes No Time/Date Collected: '■/' Comments: Collected By: Agency Code: PWS #:______ Source ID: j. » ' Type De^cnptbf^ir?^ -• --Y A, ■ ' Collected From: Bill to: 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? _2:zi£Check#:^^^£U^<e(rn^

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:_______________________ , ORGANIC NONPOTABLE/SOLI^ANAl^I^'; ORGANIC POTABLE ANALYSIS __ Heterotrophic Plate Count (hemodialysis & all others) _Trihalomethanes (524) " _ Purgeable HaIoca?bohs/(624/826p)X^-v^^^^^ ■' Volatile Halocarbons (524) _ Pdrgeabie/Arbmaiic^"{624yi^iB6)^7;^/^ __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) __ Volatile Aromatics (524) _ Acrol^r^k Adryl6niWle^(8^«O __ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) . Organochlorine Pesticides ;' (608/8081) ' Microextractables (504) _ PCB’s4^Kl6f8j:i{6^^J)'f|^^^^t __ Microscopic __ Macroscopic __ Pesticides/PCB screen (508) _ Herbicides (SM18/6630,8151 _ API __ PCB as Decachlorobiphenyl (508A) _ Other.PP§ticider(SMl3/^So)/^;^; -/ __ Other:_____________________ __ Herbicides (515) _ Petroleum Hydrocarbon S^n - (310-13) . _ 1 Pesticides (525) __ Glycols.in Water , / Refrigerated?yes no __ Carbamate Pesticides (531) _ Acid ExIractables (62^8270) ' s/j ' _Glyphosate (547) _ Base Neutral Extractables '(625/8270) ,. ' Chlorinated:?yes no __ Diquat (549) 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 (SM18/6630) pH ________ _UCMR List 1 FtADIOCHEMICAL ANALYSIS _ MtBE Only (524) __ Radon __ Other'

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Turbidity __ Aridity Aluminum __ Potassium 5 i- •w __ Alkalinity Antimony ^Selenium - . _ pH __ Bromide Arsenic __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium , - y. H __ Corrosivity (temp:. .“C) __ Chloride __ Beryllium .^Thallium' Vv.. . •/' _ BOD (5 day) __ Cyanide _ Boron __ Vanadium ;/ | __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium :'zinc _ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOs __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*2 __ Dissolved Oxygen __ Nitrogen, Nitrate as N _Metals/CN -_Chromium, Total __ Total Organic Carbon _ Volatiles ■ ' __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N _ Cobalt ■

__ Solids, Percent (%) __ Oil and Grease __ Copper __ Solids, Settleable __ Phenol __ Iron tclp __ Solids, Suspended __ Phosphorus Total as P __ Lead __ Solids, Total _TCLP-Metals __ Phosphorus, Ortho as P __ Magnesium _TCLP-Pestlcides'^';Y?:i ' __ Solids, Total Dissolved __ Sulfates __ Manganese _ TCLP-Hefbiddes’:-' __ Solids, Total Volatile __ Surfactants _i Mercury _TCLP^IatilM'lJ^^^><'- : _Z' Other: ~____________ _ UV254 Molybdenum Nickel - ■ '■'A

NYC-WTC_000072930