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 NYS-ELAP No. 10108 Time/Date Set: Form A-70 (rev. 10/01)

Sample Type (circle one); .J .,Potable 3. Non Potable Treated Bottle #’s:_____ : v-'s 2. Non Potable 4. Other Chain of Custody? Yes___ No Time/Date Collected;_________ ;________ Comments; Collected By: H - V 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 ___ a_______ CA.CH, Bl? Check#: Amounts. ■ «;■

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:_______________________ ORGANIC POTABLE ANALYsl^ 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) _L 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) _2. Herbicides (SMI 8/6630,8151) _ 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 (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 ___________ _UCMRList 1 RADIOCHEMICAL ANALYSIS _ MtBE Only (524) __ Radon __ Other_____________________

INORGANIC ANALYSIS REQUESTED - Lab#; __ Color __ Acidity j/.AIuminum __ Potassium __ Turbidity __ Alkalinity v ' Antimony Selenium _ pH __ Bromide / Arsenic y 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 CaCOa __ Calcium, as CaCOa __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*2 £LE __ Dissolved Oxygen _ Metals/CN __ Nitrogen, Nitrate as N j/Chromium, Total __ Total Organic Carbon __ Volatiles __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Total Organic Halides __ Semi-violatiles __ Nitrogen, Total Kjeldahl as N .Z Cobalt __ Solids, Percent (%) __ Pesticides/PCB’s __ Oil and Grease Z. Copper __ Solids, Settleable __ Phenol / Iron / Lead TCLP __ Solids, Suspended __ Phosphorus Total as P _TCLP-Metals __ Solids, Total __ Phosphorus, Ortho as P ___Magnesium __ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates Z Manganese __ TCLP-Herbicides __ Solids, Total Volatile __ Surfactants Z Mercury _ TCLP-Volatiles Other: _____________ _ UV254 Z Molybdenum _ TCLP-BNA’s Nickel

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