Chain of custody record with sampling and analysis fields

NYC 9/11 Public Portal Document

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ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM - '* ister WESTCHESTER COUNTY LABORATORIES AND RESEARCH 3v.com 2 Dana Road, Valhalla^ New York 10595 (914)231-1620 Fax.(914) 231-1772 .Y-- NYS-ELAP N6;4p108 Time/Date Set; Form A-70 (rev’10/01) Sample Type (circle one): 3 . *7 0/Potabl^i 3. Non Potable Treated '.Bottle #’s; *2. Non'Potable ' 4. Other _ Chain of Custody? Yes No i- Time/Date Collected: i- 7’ <- 0 3 _ Comments: Collected’ By: 3'- H IhAtz Agency Code: 2 fpWS#: Source ID: Collected From: '^''Biii to- Locatiqp’s/lndividual's Name___ i fi222^ '',MName/Company •.'StreefM^I*^_____ _ City/St/Zip_______________________ 2 ■, -Y-’- a/ -f... R Ia Identification of Source_____________ 2 ;Phon^: ___ -Fax#: _3722r^ I Ip s Collection Point 7 1^1 CA,CH, Bl? Check#:

BACTERIOLOGICAL ANALYSIS 3ab#:/' ' ' - ~ Lab#: ORGANIC POTABLEj^f^lYSIS , ;_ Heterotrophic PIate Count * •^;tirihalomethanes|(524)*- ■ (hemodialysis'&^all others) iAirvdiatile HalocarbonF(524) Purgeable Arorriati&’^^4/§26d);)^--pfe __ Coliform P/Ajj (Public supplies) Volatile Aromatics ,;)(524) . __ Acrolein,&;Acrylonitrile^260)'S^:; ,,MY> __ Coliform MPN (priv well, raw, stp) (ix^Total Trihalomethane* Potential (510) __ Organochfonne Pesticides (608/^81)'^-z/- i __ Fecal Coliform/(all samples) __ Microscopic' - Microextractables (504) J? . . j_ PCB’s (Arochlors) (608/8081) W ' __ Macroscopic _Y Pesticides/PCB screen (508) Herbicides (SMI8/6630,8151) " PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SMI8/6630j'^C/;^.,., • _ API X Herbicides (515) __ Petroleum Hydrocarbon Scan ; (3,10-133 __ Other: _ ___________________ V Pesticides (525) __ Glycols in Water . .. . s Refrigerated? _2__ yes____ no __ Carbamate Pesticides (531) _ Acid Extractables (625/8270) ... Chlorinated:?__ \ ves Free Chlorine Res:. - no . mg/L _ Glyphosate (547) , _i_ Diquat ^(549) __ Chlorination Disinfection Byproducts (551) __ Base Neutral Extractables., (625/8270) ^"’GC/MS Unknown Scan ' ; • __ Phthalates (606Me)<- I i Total Chlorine Res: .mg/L _ Haloacetic Acids (552) __ Other: . ______ _ a' _ Other Pesticides (SMI 8/6630) PH ----------------- _UCMRList1 5

RADIOCHEMICAL ANALYSIS __ MtBE Only (524) — ‘3 •' __ Radon __ Other ____________________ W

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Aiidity t ' f j M i ^j/^i’^minum ./• r/;' __Potassium I'" __ Turbidity __ Alkalinity ’ iXAntimonv _^''Selenium } , _ pH __ Bromide’ A Y jzfArsenic j;2rBilver ; _ Conductivity j^zfearium __Sodium.; A 27 - __ Corrosivity (temp;’C) ; ^YfBeryllium _2nrhallium ’ 7 _ BOD (5 day) _ Cyanide.■' ; Boron __Vanadium __ Carbonaceous BOD (5 day) __ Fluoride ' ' __:'CadmiUm i./'Zinc . ; ■./ ■> 1 _ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOs __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*^ CLE z.Sj. __ Metals/CN __ Dissolved Oxygen .4. __ Nitrogen, Nitrate as N j.^r<fhromium, Total _ Volatiles -’ __ Total Organic Carbon , __ Total Organic Halides __ Nitrogen, Nitrite as.N __ Nitrogen, Total Kjeldahl as N __ Chromium, Hexavalent .iiCobalt __ Semi-violatiles __ Pesticides/PCB's 3 __ Solids, Percent (%) __ Oil and Grease ^Copper __ Solids, Settleable __ Phenol •' ^^/on __ Solids, Suspended __ Phosphorus Total as' P j/lead ICLE _TCLP-Metals _ Solids, Total __ Phosphorus, Ortho as P. __ Magnesium __ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates j^Manganese __ TCLP-Herbicides __ Solids, TotaJ Volatile __ Surfactants .izl^ercury __ TCLP-Volatiles ' /Other: S'k"________ _ UV254 1/ Molybdenum _ TCLP-BNA's . 33 ^ZNickel

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