Chain of custody record for environmental sample testing

NYC 9/11 Public Portal Document

*i ENVIRONMENI7XL SERVICES SAMPLE SUBMISSION FORM

er^cv 'Wxiom WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (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.Potabie :3. Non Potable Treated :B||li:8SgiSWi)|i p / <y 2. Non Potable 4. Other_____________ Chain of Custody? „ Yes No nme/Date Collected:: ' " j Comments: :ii®: Collected By:_____ 1 Agency Code: ' 'i 8 Y/C.-: WMi|||BI|i||| Source ID: Type Descriptor: Collected From: Bin to: Location’s/individual’s Name i- / Name/Company iSlsSftliiliSiSS City/SVZip: City/St/Zip Identification of Source: Phone#;________ Fax#: Collection Point, ■■ Jv/ CA.CH, Bl? Check#: Amounts

BACTERIOLOGICAL ANALYSIS Big||gl||g|IBg|g^ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count __ Purgeable Halocarbons (624/8260) Volatile Halocarbons (524) __ Purgeabie Aromatics (624/8260) __ Coliform P/A (Public supplies) __ 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) .; __ Pesticides (525) __ Glycols in Water Refrigerated?yes no __ Carbamate Pesticides (631) _ Acid Extractabies (625/8270) ■■ ■

Chlorinated;? yes no __ Glyphosate (547) , Base Neutral Extractabies (625/8270) ■ _Diquat (549) r GC/MS Unknown Scan Free Chlorine Res;, mg/L Total Chlorine Res: mg/L __ Chlorination Disinfection Byproducts (551) __ Haloacetic Acids (552) ___ Other Pesticides (SM18/6630) __ Phthalates (606MS) __ Other:, ■ pH ___________ _UCMRList1 H RADIOCHEMICAL ANALYSIS _ MtBE Only (524) III

!NORGAN!C ANALYSIS REQUESTED - Lab#: 1 f __ Color IIIOfBiSiBlillliSlillllllilSlISliiBfiliOsBsBllllillliSII® __ 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 11^1 _ _ Carbonaceous BOD (5 day) __ Fluoride ___ Cadmium __ Zinc __ Soluble BOD (5 day) HaribifSs. Ibiui us C;iCO;i C.ticiun.aiit^fiCC'. _ -_ __ Chemical Oxygen Demand _ Nitrogen. Ammonia as N __ Calcium., Ca*^ __ Dissolved Oxygen Metals/CN __ Nitrogen, Nitrate as N ___Chromium, Total __ Total Organic Carbon __ Volatiles __ Nitrogen, Nitrite as N ___ Chromium, Hexavalent __ Total Organic Halides _ Solids, Percent ("/«) __ Nitrogen. Total Kjeldahl as N __ Oil and Grease ___ Cobalt ___ Copper __ Semi-violatiles ... Poslicide:'l'CBs ■■ ■ r-r............. ■ . ... Solids, Settleable -.Phe.:o! Iron ■ __ Solids, Total Dissolved __ Solids, Total Volatile .. .. oulmtec. __ Surfactants : S:= .. Manguneso _ MGrcury . ..... _ TCLP-Pesticides

Other' __ UV254 „„ Molybdenum

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