Chain of custody record, Westchester County Labs, Feb 2002

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH C? 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): 1 ..Potable 3. Non Potable Treated Bottle #’s: 2. Non Potable 4. Other____________ Chain of Custody? Yes___ No Time/Date Collected: Comments: t ,

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 I CA,CH, Bl? Check#: Amounts

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:_______________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count __ Trihalomethanes (524) (hemodialysis & all others) __ Purgeable Halocarbons (624/8260) __ 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 (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) _L-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 (SM18/6630) pH ___________ _ UCMR List 1 RADIOCHEMICAL ANALYSIS _ MtBE Only (524) Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ /k:idity 2/ Aluminum __ Potassium __ Turbidity __ Alkalinity Antimony _ Selenium _ pH __ Bromide _ i 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 __ Chemical Oxygen Demand CLP __ Nitrogen, Ammonia as N __ Calcium, Ca*2 __ Dissolved Oxygen __ Nitrogen, Nitrate as N _ Metals/CN __Chromium, Total __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Volatiles __ Chromium, Hexavalent __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N __ Semi-violatiles __ ^Cobalt __ Solids, Percent (%) __ Pesticides/PCB's __ 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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