Chain of Custody Record, Westchester County Dept of Labs

NYC 9/11 Public Portal Document I

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

Sample Type (circle one): ' 1. Potable 3. Non Potable Treated Bottle #’s: I YI ■4 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 Name/Company Street______________________ Street_______ City/St/Zip__________________ City/SVZip F Identification of Sou rce________ ' -it, Phone#: Fax#: 4 Collection Point u- - CA,CH, Bl? Check#: Amounts ■a

BACTERIOLOGICAL ANALYSIS Lab#: L^LLJ. Lab#:_______________________ : :/ j t '■ \ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS ^ fl __ Heterotrophic Plate Count (hemodialysis & all others) __ Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) __ poliform P/A (Public supplies) __ Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Ooliform MPN (priv well, raw, stp) __ Fecal Coliform (all samples) __ Microscopic __ Volatile Aromatics (524) __ Total Trihalomethane Potential (510) __ Microextractables (504) __ Acrolein & Acrylonitrile (8260) __ Organochlorine Pesticides (608/8081) _ PCB’s (Arochlors) (608/8081) i __ Macroscopic __ Pesticides/PCB screen (508) _ Herbicides (SMI8/6630,8151) API __ I Other: __ PCB as Decachlorobiphenyl (508A) ,__ Herbicides (515) __ Pesticides (525) _ Other Pesticides (SMI8/6630) __ Petroleum Hydrocarbon Scan (310-13) _ Glycols in Water I I* Refrigerated? Chlorinated:? yes___ no 2— yes no __ Carbamate Pesticides (531) __ Glyphosate (547) __ Acid Extractables (625/8270) __ Base Neutral Extractables (625/8270) I __ Diquat (549) __ ' GC/MS Unknown Scan Free Chlorine Res:. . mg/L Total Chlorine Res: I pH ___________ . mg/L __ Chlorination Disinfection Byproducts (551) __ Haloacetic Acids (552) __ Other Pesticides (SMI 8/6630) __ Phthalates (606MS) __ Other:_____________ 1 —V’ I _UCMRList 1 ^RADIOCHEMICAL ANALYSIS _MtBEOnly (524) -S __ [Radon __ Other_____________ __

INORGANIC ANALYSIS REQUESTED - Lab#: ■ Color _ Turbidity __ Acidity __ Alkalinity __ Aluminum __ Antimony __ Potassium _2_ Selenium. / / 4 _L pH __ Bromide ' __ Arsenic - Silver f 4-1/ ! _L Conductivity __ Bromate/Chlorate/Chlorite ■ __ Barium __ Corrosivity (temp:. f BOD (5 day) °C) __ Chloride __ Cyanide __ Beryllium __ Boron __ Sodium' __ Thallium __ Vanadium ■)

I _L Carbonaceous BOD (5 day) _ Soluble BOD (5 day) __ Fluoride __ Hardness, Total as CaCOa __ Cadmium __ Calcium, as CaCOa __ Zinc ?? T; __ Chemical Oxygen Demand CLP __ Nitrogen, Ammonia as N __ Calcium, Ca+2 __ Dissolved Oxygen _ Metals/CN __ Nitrogen, Nitrate as N __ Chromium, Total I 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 arid Grease __ Copper 1_ Solids, Settleable __ Phenol __ Iron t PM TCLP __ Solids, Suspended _ Phosphorus Total as P __ Lead 1_ Solids, Total _TCLP-Metals __ Phosphorus, Ortho as P __ Magnesium _ Solids, Total Dissolved __ TCLP-Pesticides I __ Sulfates __ Manganese __ Solids, Total Volatile __ TCLP-Herbicides __ Surfactants __ Mercury !_ Other: ____________ _ TCLP-Volatiles __ UV254 _ Molybdenum _ TCLP-BNAs __ Nickel

NYC-WTC_000073415