Chain of custody record with sampling and analysis fields

NYC 9/11 Public Portal Document

vK ACCOi T ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM tester WESTCHESTER COUNTY LABORATORIES AND RESEARCH I novcom 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 NYS-ELAPNo. 10108,... Time/Date Set: Form A-70 (rev. 10/01)

Sample Type (circle one): ■ 1. PotableJ 3. Non Potable Treated Bottle #’s: / 2. Non Potable 4. Other Chain of Custody? Yes___ No Time/Date Collected: Comments: ’■ '■ Wt-

Collected By: _______ Agency Code: PWS #:________ Source ID: Type Descriptor: Collected From: Bill to: Location’s/lndividual’s Name. Name/Company _ Street__________________ Street_________ City/St/Zip_______________ City/SVZip Identification of Source Phone#:_______ _____ pax#:-: Collection Point I CA,CH, Bl? _______ Li Check#: Am6urit$2^^YZ'

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:_______________________ ORGANIC POTABLE ANALYSIS __ Heterotrophic Plate Count __ Trihalomethanes (524) (hemodialysis & all others), ' __ Volatile Halocarbons (524) __ Purgeable Aromatics - (624/8260)'/Y- __ Coliform P/A (Public supplies) __ Volatile Aromatics (524) ' _ Acrolein & Acrylonitrile’ (826b)>^?>^^ __ Coliform MPN (priv well, raw, stp) __ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) ■

__ Microscopic __ Microextractables (504) __ Pesticides/PCB screen (508) _ • Herbicides (SM18/663&',8151’)W __ Macroscopic _ API __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SM18/6M0);^;O:>ri;:^ _ Herbicides (515) __ Petroleum Hydrocarbon .Scan , (316-13) __ Other:_____________________ __ Pesticides (525) __ Glycols in Water " Refrigerated?yes no __ Carbamate Pesticides (531) Acid Extractables (6^/8270) J __ Glyphosate (547) JSase Neutral Extractables'(625/8270)/'Y- Chlorinated:?yes___ no __ Diquat (549) j::^^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) 7' tS-' pH ___________ _UCMRList1 RADIOCHEMICAL ANALYSIS _ MtBE Only (524) Radon __ Other____________________ : i i

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Acidity Aluminum __ Potassium __ Turbidity __ Alkalinity __; Antimony __ ^"Selenium ■ — pH __ Bromide __ ;'Arsenic —'Silver __ 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 • V y: ■ _ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOs __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N _^Calcium, Ca*^ cue ZZ^Chromium, Total _Metals/CN' __ Dissolved Oxygen __ Nitrogen, Nitrate as N — Volatiles . __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent _ Semi-vlolatiles’Y-rfv^^; __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N _ Cobalt __ Pesticides/PCB’s __ Solids, Percent (%) __ Oil and Grease __ Copper __ Solids, Settleable __ Phenol _ Iron __ Solids, Suspended __ Phosphorus Total as P __ Lead ICLE _TCLP-Metals __ Solids, Total __ Phosphorus, Ortho as P __ Magnesium _TCLP-Pesticld^;^^i^^ __ Solids, Total Dissolved __ Sulfates __ Manganese _ TCLP-Herbicides ^Solids. Total Volatile __ Surfactants __ Mercury _ TCLP-VolatilesY'''Y?vO Other: _________ _ UV254 __ Molybd^um __ Nickel

NYC-WTC_000072931