Chain of custody record with sampling and analysis fields

NYC 9/11 Public Portal Document

'■Il ACOa. ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ster ivcom WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914) 231-1620 Fax (914) 231-1772 < NYS-ELAP No/ IOlOa Time/Date Set: Forrn A-70 (revj 0/01)

Sample Type (circle one): f..

/1 jPotable 3. Non Potable Treated Bottle #’s: '2. Non Potable 4. Other___________________ Chain of Custody? Yes No Time/Date Collected: Comments: ,• ■salp Collected By: < ______ Agency Code: PWS #:________ Source ID: .Type Descriptor: ■2£ Collected From; Bill to: 1 Location's/lndividual's Name Name/Company Street Street_________ City/St/Zip______________ City/St/Zip Identification of Source Phone#:_______ Fax#: Collection Point rCA,CH, Bl? Cl;ieck#: i

BACTERIOLOGICAL ANALYSIS . Lab#: Lab#:________________________ ORGANIC POTABLE ANALYSIS ORGANIC N6NPOTABLE/SbubANALYS)sM __ Heterotrophic Plate Count _i>Trihaldmeihanes (524) __ Purgeable rialoMrbons^(62^i3260j'^|-|^^{ (hemodialysis & all others) __ Volatile Halocarbons (524) __ Purgeable Aromatics (624-/8260) __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) _ Volatile Aromatics (524) _ Acrolein’s Acrylonitrile (8260)’ . :__ Total Trihalomethane Potential (510) _ Organdcfilonne Pestidcie^^(608/8081^^i^ __ Fecal Coliform (all samples) __ Microscopic __ Microextractables (504) _ PCB’s (Arochlors)-(608/8081) •; __ Macroscopic __ Pesticides/PCB screen (508) _ Herbicides (SM18/663b,8151) _ API __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides -ftSMI 8/6630) __ Herbicides (515) __ Petroleum Hydrocarbon Scan (:^|||B|B^ __ Other:_____________________ _ Pesticides (525) __ Glycols in Water' - Refrigerated?yes___ no _ Carbamate Pesticides (531) _ Acid Extractables (625/8270) Chlorinated:?yes___ no -j_ Glyphosate (547)' __ Base Neutral Extractables (625/8270) Diquat (549) - GC/MS Unknown Scan ' Free Chlorine Res:mg/L __ Chlorination Disinfection Byproducts (551) _ Phthalates (606MS) :: y- >

Total Chlorine Res:mg/L __ Haloacetic Acids (552) __ Other:______________ __ Other Pesticides (SMI8/6630) pH ___________ RADIOCHEMICAL ANALYSIS __ Radon _UCMR Listi _ MtBE Only (524) zfl __ Other____________________ /' •< t r INORGANIC ANALYSIS REQUESTED - Lab#: i / I I ? __ Color __ Aridity Aluminum __ Potassium __ Turbidity __ Alkalinity __ Antimony __ Selenium ■. _ pH __ Bromide __ Arsenic __ Silver __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium . __ Corrosivity (temp:. .’C) __ Chloride '__ Beryllium __ Thallium _ BOD (5 day) __ Cyanide _ Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride ’ __ Cadmium __ Zinc _ Soluble BOD (5 day) __ Hardness,' Total as CaCOa __ Calcium, as CaCOs __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*^ CLE __ 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 __ Semi-violatiles __ Cobalt __ Solids, Percent (%) __ Pesticides/PCB’s __ Oil and Grease __ Copper __ Solids, Settleable __ Phenol __ Iron __ Solids, Suspended __ Phosphorus Total as P __ Lead TCLP ■w _TCLP-Metals __ Solids, Total __ Phosphorus, Ortho as P __ Magnesium __ Solids, Total Dissolved ,, __ Sulfates _TCLP-Pesticides __ Manganese __ Solids, Total Volatile __ Surfactants _TCLP-Herbicides __ Mercury __ UV254 _ TCLP-Volatiles Other: _ _____________ __ __ Molybdenum _ TCLP-BNA’s _ Nickel J

NYC-WTC_000072933