Chain of custody record for environmental sample testing

NYC 9/11 Public Portal Document ■ W 'hr !- ENVIRONMENTAL SERVICES SAMPLE SUBMiSSiON FORM \’^^QTA:cO1 I i WESTCHESTER COUNTY LABORATORIES AND RESEARCH !■ ■ 2 Dana Road, Valhalla. New York 10595 • « (9,4)231.1620 Fax (914,231-»72 , NYS-ELAP No. 10108 Time/Date Set: ...... Form A-70 (rev. 10/01)

Samplsjype ,ci,d,„„.); ■ ■ 2- Po.aee,y 3. Non Polable Twated . Bol.o #'s: ■I 2. Non Potable 4. Other________________ _________ Chain of Custody?___ Yes___ No Time/Date Collected: Comments:~ Cl *

Collected By:j2_________ /./____ Agency Code: PWS #: Source ID; Type Descriptor: Collected From: Bill to: Location’s/lndividual’s Name hjc At? Name/Company _ Street {/iP'Y- , DCbJt Street I III City/SVZip Identification of Source ; iiifioiSiilllliis Fax#: Collection Point _____ : CA.CH, Bl? Check#: Amounts___ .

BACTERIOLOGICAL ANALYSIS •Lab#:

ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Purgeable Halocarbons (624/8260) __ Coliform P/A (Public supplies) __ Purge, ilili' Aionuitics. {»>?4/8?li0; __ Coliform MPN (pnv well, raw, stp) Volatile Aromatics (524) Aciolinsi Acivliinitrik- (H^BO) __ 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 (SM18/6630.8151) __ API __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SMI8/6630) __ Other; IO >■_ Herbicides (515) Petroleum Hydrocarbon Scan (310-13) - ) _ Pesticides (525) __ Glycols in Water Refrigerated?yes Chlorinated:?yes no no ;' _ Carbamate Pesticides (531) _ Glyphosate (547) ill Acid Extractables (625/8270) _ Base Neutral Extractables (625/8270) _ Diquat (549) , .-.r.'MS Unl.linm, FlX.n Free Chlorine Res: niq/l. _ Chlorination Disinfection Byproducts (551)' Total Chlorine Res:mg/L __ Haloacetic Acids (552) pH ___________ _Other Pesticides (SMI8/6630) ^BIH _UCMRList1 1- RADIOCHEMICAL ANALYSIS i __Radon _ Other:

iNORGANfC ANALYSIS REQUESTED - Lab#: ( __ Acidity __ Aluminum <_ Potassium __ Turbidity __ Alkalinity >^Antimonv Scii-nium pH^ __ Bromide __ Arsenic Silver _ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium __ Chloride xSBeryllium X'Thallium : ' _ BOD (5 day) __ Cyanide __ Boron Vanadium , - __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Zinc ___ Soluble BOD (5 day) __ Chemical Oxygen Demand __ Hardness, Total as CaCOa __ Nitrogen, Ammonia as N __ Calcium, as CaCOal __ Calcium, Ca+2 ■ CLP ■ __ Dissolved Oxygen __ Nitrogen, Nitrate as N __ Metals/CN __ Chromium, Total 2_ Total Organic Carbon __ Volatiles ; __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N XCobalt Solids, Percent (%) __ Oil and Grease ___ Copper .... Seine..bln .... Plumol Y- Iron ■ IB _ Solids, Total Dissolved _ Sulfates '<Manganese tclp TCI P-Metais IC! P-P.jsticidfcs i ■ S«s, Total V5«e - = TCLP.wfa,'£/les: i — -UV264 .. . ICtPJ 'MA’c !S

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