Chain of custody record, Jan 2002

NYC 9/11 Public Portal Document OsiMii

environmental SERVICES SAMPLE SUBMISSION FORM Bi y?<>wro!n Westchester county laboratories and research , 2 Dana Road, Valhalla, New York 10595 (914)231-162.0 Fax (914) 231-1772 <ESS NYS ELAPNo I0108 x

Time/Date Set: Form AVI)!rev. 1U/01)

Sample.Jype (circle one): , 1 Point lie / 3. Non Potable Treated Bottle #’s; 2. Non Potable 4. Other..... Chain of Custody? Yes No r-- vC'<- ft' Time/Date Collected:__ /___ Comments: Collected By; Agency Code: PWS #;_______ Source ID: Type Descriptor; Coliected From: Bill to: Location’s/lndividual's Name X I .’S. l"^ Name/Company Street liSWIIliiiBIII City/StfZip City/St/Zip■ Identification of Source___________ iPfeWitBSBiiji Fax#: Collection Point CA.CH, Bl? Check#; Amounts

BACTERIOLOGICAL ANALYSIS Lab#:

ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count __ Purgeable Halocarbons (624/8260) Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) ___ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) J>-Volatiie 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) __ PCB as Decachlorobiphenyi (508A) Other Pesticides (SM18/6630) __ API __ Other:_______________________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) __ 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) y^GC/MS Unknown Scan Free Chlorine Res: mg/L __ Chlorination Disinfection Byproducts (551) „ Phthalates (606MS) Total Chlorine Res: _ mg/L __ Haloacetic Acids (552) Other; __ Other Pesticides (SM18/6630) pH _________ ____ __UCMRList1 RADIOCHEMICAL ANALYSIS _ MtBE Only (524) ___ Radon #s ■■

INORGANIC ANALYSIS REQUESTED - Lab#;, ■ __ Color — Acidity __ Aluminum ,. V'- ' Potassium __ Turbidity __ Alkalinity X Antimony X •' Selenium ; pH __ Bromide ___ Arsenic ; .__Silver __ Conductivity __ Bromate/Chlorate/Chlorite ___ Barium __ Sodium __ Corrosivity (temp;. °C) __ Chloride .2S. Thallium BOD (5 day) Cyanide __ ‘Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride _ Cadmium . Soluble BOD (5 day) __ Hardness, Total as CaCOa _ __ Calcium, as CaCOa ________________ CLP ___ Chemical Oxygen Demand _ Nitrogen, Ammonia as N __ Calcium, Ca*’ __ Dissolved Oxygen __ Metals/CN __ Nitrogen, Nitrate as N ___ Chromium. Total _ Volatiles __ Total Organic Carbon ... Nitrogen. Niiritt ns N .... Chromium, Hexavalent _ Semi-violatiles TotalOrganic __ total OrganicHalides Halides Nitrogen, Total Kjeldahl as N Cobalt „ , _.Pe,Mdes;PCB.s

-sr” ■■ .. Solids. Tota! D' /.oIv.m

: gS- . Sulintes Manqanes.;

-S5^ I II _____________________________________________________________________________________________ ■ .............................................................. ■ . ■

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