Chain of custody record for DEP samples, February 2002

NYC 9/11 Public Portal Document

>,» ACCo ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM lester fev.com 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): . J. Pota^/ 3. Non Potable Treated Bottle #’^: X'Ar V 2. Non Potable 4. Other Chain of Cuslodt^^-Yes' )

Time/Date Collected:_____ ■. '■ ; 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_____ "cO_____________________ I CA.CH, Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:_______________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count __ Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) (hemodialysis & all others) __ Volatile Halocarbons (524) __ Purgeable 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 (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) __ 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 (SMI8/6630) pH ------------------- _UCMR Listi RADIOCHEMICAL ANALYSIS _MtBE Only (524) __ Radon __ Other____________________

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

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