Chain of custody record with sampling and analysis fields

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM tester 5pv.com WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 NYS-ELAP No. iow' Time/Date Set: .Form A:7a(taKio/qi);i' ■ ' /

Sample Type (circle one): , 1. Potable 3. Non Potable Treated Bottle #’s: £ 2. Non Potable 4. Other Chain of Custody? Yes No Time/Date Collected: £ f Comments: 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/St/Zip Identification of Source Phone#:_______ Fax#: ■w -x Collection Point 1 I CA,CH, Bl? jj- Check#: iBYLLj:£L?'^m6unt^^

BACTERIOLOGICAL ANALYSIS . Lab#:_______________________ __ Heterotrophic Plate Count, Lab#:

ORGANIC POTABLE ANALYSIS -S’iSSSiBwaa® (hemodialysis & all others) / __ Trihalomethanes (524) I __ Volatile Halocarbons (524) _ Purgeable Aromatics (624/8260)’' YY;iY^ . __ Coliform P/A (Public supplies) __ Volatile Aromatics (524) Acrolein & Acrylonitrile "(^60}^ __ Coliform MPN - (priv well, raw, stp) __ Fecal Coliform'(all samples) __ Total Trihalomethane Potential (510) _ Organqchlorine Pesticides (608/8081 j < __ Microscopic ' . __ Microextractables (504) PCB’s (Arochlors): (608^081) 7. __ Macroscopic • __ Pesticides/PCB screen (508) _ HertilcidesXSMtS/6630,8151 __ API __ PCB as Decachlorobiphenyl (508A) _ Othdr Pesticides' (SM18/6630)- B __ Other;_____________________ _ Herbicides (515) __ Pesticides (525) Refrigerated?yes no __ Carbamate Pesticides (531) , _ Acid Extractables (625/8270) , e . Y Chlorinated;?yes no _ Glyphosate (547) _ . Diquat .(549). . Free Chlorine Res: . mg/L __ Chlorination Disinfection Byproducts (SSI)" __ PhthalatesXS06f\/fe) ' . s" YY Total Chlorine Res; . mg/L _Haloacetic Acids (552) _ Qther'^-^-J!^ B"' ■ pH ___________ RADIOCHEMICAL ANALYSIS Radon _ Other Pesticides (SMI8/6630) _UCMRList1 _ MtBE Only (524) a __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Acidity JlAluminum __ Potassium __ Turbidity __ Alkalinity _ Antimony __ .'Selenium _ pH __ Bromide __ Arsenic f __ ' Silver __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ ; Sodium __ Corrosivity (temp:. _ BOD (5 day) .“C) _ Chloride __ Cyanide _ Beryllium __ Boron ^Thallium •' '..W: __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Zinc ■■'Sb __ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ 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 __ Nitrogen, Nitrite as N _ Volatiles „ __ Chromium, Hexavalent __ Total Organic Halides _Semi-violatiles' __ Nitrogen, Total Kjeldahl as N _''Cobalt __ Solids, Percent (%) __ Oil and Grease _ Pesticides/PCB’s,- - __ Copper __ Solids, Settleable __ Phenol __ Iron , V,.., __ Solids, Suspended __ Phosphorus Total as P __ Lead ickE .4*^ , __ Solids, Total __ Phosphorus, Ortho as P _TCLP-Metals __ Magnesium __ Solids, Total Dissolved _TCLP-Pesticides __ Sulfates Manganese _ Solids, Total Volatile _TCLP-Herbicides __ Surfactants 'Mercury _ tCLP-Volatiles h Other:_____ ___________ _ UV254 __ Molybdenum _ Nickel

NYC-WTC_000072932