Chain of custody record with sampling and analysis fields

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM lester WESTCHESTER COUNTY LABORATORIES AND RESEARCH [ovcom 2 Dana Road, Valhalla, New York 10595 0/1 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): • 1. Potable 3. Non Potable Treated Bottle #’s: G/ L- 2. Non Potable 4. Other Chain of Custody? Yes No Time/Date Collected: Comments: Collected By: j > J Agency Code: / Z 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#: Collection Point iVjU I CA,CH, Bl? Check#: Amounts.

I BACTERIOLOGICAL ANALYSIS Lab#: Lab#: _ _______ ______________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count _X-Purgeable Halocarbons (624/8260) (hemodialysis & all others) __ Trihalomethanes (524) __ Coliform P/A (Public supplies) __ Volatile Halocarbons (524) Purgeable Aromatics (624/8260) __ Coliform MPN (priv well, raw, stp) __ Volatile Aromatics (524) _ :' Acrolein & Acrylonitrile (8260) __ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081) __ Microscopic __ Microextractables (504) _:' PCB’s (Arochlors) (608/8081) __ Macroscopic __ Pesticides/PCB screen (508) _ Herbicides (SMI8/6630,8151) _ API __ PCB as Decachlorobiphenyl (508A) _£ Other Pesticides (SM18/6630) __ Other:_____________________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) f __ Pesticides (525) _ _ Glycols in Water Refrigerated?yes no __ Carbamate Pesticides (531) _ Acid Extractables (625/8270) Chlorinated:?yes no __ Glyphosate (547) _ Base Neutral Extractables (625/8270) _ Diquat (549) △ GC/MS Unknown Scan Free Chlorine Res: . mg/L __ Chlorination Disinfection Byproducts (551) ■_ Phthalates (606MS) Total Chlorine Res: . mg/L __ Haloacetic Acids (552) _ Other:___________________________ 1 _ Other Pesticides (SMI 8/6630) pH ------------------- _UCMR Listi RADIOCHEMICAL ANALYSIS _ MtBE Only (524) __ Radon _ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Aridity । a±Q-------- __ 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 CaCOa __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*2 CLE __ Metals/CN ; __ Dissolved Oxygen __ Nitrogen, Nitrate as N __ Chromium, Total _ Volatiles i __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Semi-violatiles __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N __ Cobalt __ Pesticides/PCB's __ Solids, Percent (%) __ Oil and Grease __ Copper __ Solids. Settleable __ Phenol ■* __ Iron TCLP __ Solids, Suspended __ Phosphorus Total as P __ Lead _TCLP-Metals __ Solids, Total __ Phosphorus, Ortho as P __ Magnesium I __ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates __ Manganese __ TCLP-Herbicides __ Solids, Total Volatile __ Surfactants __ Mercury _ f CLP-Volatiles __ Other: ’_____________ _ UV254 __ Molybdenum _ TCLP-BNA’s __ Nickel

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