Chain of custody record for DEP samples, February 2002

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM tester novcom 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 AYO (rev. 10/01)

Sample Type (circle one): 1. Potable 3. Non Potable Treated Bottle #’s: 2. Non Potable 4. Other Chain of Custody?___ Yes No Time/Date Collected: ' Comments: Collected By:___________ Agency Code: PWS #:______ Source ID: Type Descriptor; Collected From: Bill to; Location’s/lndividual’s Name O J » 7 Name/Company Street_________________ Street________ City/St/Zip______________ City/St/Zip Identification of Source Phone#: Fax#: Collection Point I CA.CH. Bl? Check#: Amounts '

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:_______________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count __ Purgeable Halocarbons (624/8260) ’ (hemodialysis & all others) __ Trihalomethanes (524) __ Coliform P/A (Public supplies) __ Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) J_ 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 (SM18/6630.8151) _ API __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SMI8/6630) ' " __ 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) _i£fGC/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 ------------------- _UCMRList 1 RADIOCHEMICAL ANALYSIS _ MtBE Only (524) __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Acidity __ Aluminum __ Potassium __ Turbidity __ Alkalinity __ Antimony _.Selenium _ pH __ Bromide Arsenic _ Silver ' __ Conductivity __ Bromate/Chlorate/Chlorite _ Barium __ Sodium __ Corrosivity (temp: “C) __ Chloride _l'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 CaCOs CLP __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium. Ca*^ __ Dissolved Oxygen _ Metals/CN __ Nitrogen, Nitrate as N _lChromium, Total __ Total Organic Carbon __ Volatiles __ Nitrogen, Nitrite as N __ Chromium. Hexavalent __ Total Organic Halides __ Semi-violatiles __ Nitrogen, Total Kjeldahl as N __^Cobalt __ Solids. Percent (%) __ Pesticides/PCB’s __ Oil and Grease __ Copper __ Solids. Settleable __ Phenol __ Iron __ Solids. Suspended __ Phosphorus Total as P TCLP __ Lead __ Solids. Total _TCLP-Metals __ Phosphorus. Ortho as P __ Magnesium __ Solids. Total Dissolved __ TCLP-Pesticides __ Sulfates __ Manganese __ Solids. Total Volatile __ TCLP-Herbicides __ Surfactants __ Mercury __:,''Other: _ TCLP-Volatiles _ UV254 __ Molybdenum _ TCLP-BNA’s __ Nickel

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