Chain of custody record for DEP samples, February 2002

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM tester jov.com WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 neac NYS-ELAP No. 10108 Time/Date Set: Form A-70 (rev. 10/01)

Sample Type (circle one): ■■ '‘T 1 .Potable 3. Non Potable Treated Bottle #’s: 2. Non Potable 4. Other____________ Chain of Custody? Yes No Time/Date Collected: V \ ' .V C 2. Comments: Collected By: ‘ " Agency Code: 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________ 1- H \ L) < I CA,CH, Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:_______________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count , (hemodialysis & all others) __ Trihalomethanes^524) __ Purgeable Halocarbons (624/8260) __ 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 (SM18/6630,8151) _ API __ PCB as Decachteajpiphenyl (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) _L'GC/MS Unknown Scan Free Chlorine Res: . mg/L __ Chlorination Disinfection Byproducts (551) _ Phthalates (606MS) Total Chlorine Res; . mg/L __ Haloacetic Acidg*T562) __ Other:____________________________ __ Other Pesticides (SMI8/6630) pH ___________ _UCMRList1 RADIOCHEMICAL ANALYSIS _ MtBE Only (524) __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Acidity Il Aluminum __ Potassium __ Turbidity __ Alkalinity , 4. Antimony _ Selenium _ pH 5 ■ Bromide i ' Arsenic 2::. Silver __ Conductivity __ Bromate/Chlorate/^jihlorite Barium __ Sodium __ Corrosivity (temp :L2°C) __ Chloride LL'Beryllium Thallium _ BOD (5 day) __ Cyanide __ Boron __ Vanadium ____ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium I- ■ Zinc __ Soluble BOD (5 day) __ Hardness, Total as CaCOs ' __ Calcium, as CaCOs __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*^ CLE __ Dissolved Oxygen __ Metals/CN __ Nitrogen, Nitrate as N i^Chromium, Total __ Total Organic Carbon _ Volatiles __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Total Organic Halides __ Semi-violatiles __ Nitrogen, Total KjeldaW as N LrGobalt __ Solids, Percent (%) __ Pesticides/PCB’s __ Oil and Grease Copper __ Solids, Settleable __ Phenol Iron TCLP __ Solids, Suspended __ Phosphorus Total as P J- Lead __ Solids, Total _TCLP-Metals __ Phosphorus, Ortho as P __ Magnesium __ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates ' Manganese __ TCLP-Herbicides __ Solids, Total Volatile __ Surfactants Ll Mercury Other: 'Y; _______ _ UV254 _ TCLP-Volatiles LL Molybdenum LA _ TCLP-BNA’s i^i'Nickel

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