Chain of custody record, Westchester County Labs, Feb 2002

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ACCo 5 WESTCHESTER COUNTY LABORATORIES AND RESEARCH

Time/Date Set: 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 ,< NYS-ELAP No. 10108 Form A-70 (rev. 10/01) 3 j > ' > ,,, T. Sample Type (circle one); > 7 ',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; I Location’s/lndividual’s Name Name/Company Street_________________ Street_______ I City/St/Zip______________ City/St/Zip I Identification of Source

3 Phone#:_ Fax#: I Collection Point CA,CH, Bl? Check#; Amounts

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:_______________________ __ Heterotrophic Plate Count ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS i __ Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) (hemodialysis & all others) __ Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) 1 __ Coliform P/A (Public supplies) '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 (SMI8/6630,8151) _ API __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SM18/6630) __ Other:_____________________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) __ Pesticides (525) __ Glycols in Water I 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:____________________________ I _ Other Pesticides (SM18/6630) pH __ UCMR List 1 I RADIOCHEMICAL ANALYSIS _MtBE Only (524) , __ Radon __ Other.

INORGANIC ANALYSIS REQUESTED - Lab#: / / / __ Color __ Acidity Aluminum __ Potassium I _ Turbidity __ Alkalinity . __ Antimony __ 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 CaCOa __ Calcium, as CaCOa CLP __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*2 ) _ Metals/CN __ Dissolved Oxygen __ Nitrogen, Nitrate as N _^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 __ Iron TCLP __ Solids, Suspended __ Phosphorus Total as P Lead _TCLP-Metals __ Solids, Total __ Phosphorus, Ortho as P __ Magnesium __ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates __ Manganese __ TCLP-Herbicides __ Solids, Total Volatile __ Surfactants __ Mercury _ TCLP-Volatiles __ Other: >■-____________ _ UV254 __ Molybdenum _ TCLP-BNA’s Nickel

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