Chain of custody record with sampling and analysis fields

NYC 9/11 Public Portal Document

s' ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ster WESTCHESTER COUNTY LABORATORIES AND RESEARCH ivcom 2 Dana Road, Valhalla, New York 10595 O/ ■ I (914)231-1620 Fax (914) 231-1772 NYS-ELAP No. 10108 Time/Date Set: Form A-70 (rev. 10/01)

Sample Type (circle one): ■■ ..S‘ > t'f

• I.Potable 3. Non Potable Treated Bottle #’s:____________________ 2. Non Potable 4. Other____________ Chain of Custody?___ Yes No I

Time/Date Collected:: iI 4 Comments: Collected By: - Agency Code: PWS #:______ Source ID: .Type Descriptor: Collected From: Bill to: Location's/lndividual's Name QU Name/Company Street Ju_________ Street________ City/St/Zip______________ City/St/Zip Identification of Source Phone#: Fax#: -i Collection Point 't: —I CA,CH, Bl? Check#: A<.':/Amdunt$

BACTERIOLOGICAL ANALYSIS /Lab#: Lab#:_ dilGANlC POTABLE ANALYSIS _ Heterotrophic Plate Count ijETrihalomethanes (524) ‘S; v. . (hemodialysis & all others) _ Volatile Halocarbons (524) _^Purgeable Aromatics;(624/8260) Y __ Coliform P/A (Public supplies) Volatile Aromatics (524). ... , "Acrolein & Acryl<^t^e^(^6P).Uii __ Coliform MPN (priv well, raw, stp) _ Total Trihalomethane Potential (510) __ OrganochlorinePesticides'.(608/8081) 7. __ Fecal Coliform (all samples) Microextractables (504) _ PCB's (Arochlors) (608/8081). /, U __ Microscopic U Pesticides/PCB screen (508) _ Herbicides (SMI8/6630,8151) -U • __ Macroscopic _ PCB as Decachlorobiphenyl (508A) :__Other Pesticides (SMI8/6630) Y . _ API _ Other:____________________ _ Herbicides (515) __ Petroleum Hydrocarbon Scan :(310-13) _ Pesticides (525) __ Glycols in Water •- Refrigerated?yes___ no _ Carbamate Pesticides (531) _ Acid Extractables (625/8270) . . ; __ Glyphosate (547) zBase Neutral Extractables (625/8270)<^'• Chlorinated:?yes___ no U GC/MS Unknown Scan .. ’S'/ _Diquat'(549) 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 ____ _______ __ UCMR Listi RADIOCHEMICAL ANALYSIS _MtBE Only (524) __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: U ’ __ Color __ Aridity __ Aluminum __ Potassium -J __ Turbidity __ Alkalin^,, . Antimony __ Selenium ; — pH __ Bromidb _ Arsenic __ Silver f __ Conductivity __ Bromate/Chlorate/Chlorite Barium __ Sodium j __ Corrosivity (temp :_2__®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 CaCOa £LE i ” __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*’ _Metals/CN .. __ Dissolved Oxygen __ Nitrogen, Nitrate as N ^Chromium, Total _ Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Semi-violatiles ; __ Total Organic Halides _ Nitrogen, Total Kjeldahl as N V. Cobalt _ Pesticides/PCB’s /' __ Solids, Percent (%) __ Oil and Grease _i. 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 Volatile __ Surfactants __ Mercury __ TCLP-Volatiles U Other:. __!Us_________ _ UV254 __ Molybdenum _ TCLP-BNA's ’ .. J'' . Nickel

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