Chain of Custody Record, Sample AE03388, Feb 2002

NYC 9/11 Public Portal Document

1 ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ! Afesctiester WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 s/LRataJL.): NYS-ELAP No. 10108 Time/Date Set: Form A-70 (rev. 10/01) a J Sample Type (circle one): 1. Potable :3. Non Potable Treated Bottle #’s: PiUi Bi 2. Non Potable -4. Othei Chain of Custody?___ Yes___ No Time/Date Collected: Comments: Collected By: _ l/Xb Agency Code; PWS #:______ Source ID: Type Descriptor; Collected From: Bill to: Location’s/lndividual's Name , I'yku-bL. Name/Company . Street_________________ Street_______ City/St/Zip ___ ___________ City/St/Zip Identification of Source Phone#; Fax#: I Collection Point CA,CH, Bl? Check#: Amounts.

1. BACTERIOLOGICAL ANALYSIS Lab#: < f . Lab#:_____________ __________ I ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS 1 __ Heterotrophic Plate Count I (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) __ Acrolein & Acrylonitrile (8260) i. __ Total Trihalomethane Potential (510) _ Organochlorine Pesticides (608/8081) __ Fecal Coliform (all samples) __ Microscopic __ Microextractables (504) _ PCB’s (Arochlors) (608/8081)- I __ Macroscopic __ Pesticides/PCB screen (508) _ Herbicides (SM18/6630,8151) 1 _ API __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SM18/6630) __ Other:____________________ _ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) __ Pesticides (525) __ Glycols in Water 1 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) J Total Chlorine Res:mg/L __ Haloacetic Acids (552) __ Other;____________________________ __ Other Pesticides (SMI 8/6630) pH ___________ _ UCMR List 1 RADIOCHEMICAL ANALYSIS _ MtBE Only (524) J __ Radon _ Other.

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ /Acidity __ Aluminum __ Potassii __ Turbidity __ Alkalinity _ Antimony __ Seleniul _ pH- __ Bromide * __ Arsenic j_ Silver ( __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium __ Corrosivity (temp; .’C) __ Chloride __ Beryllium , __ Thalliumf •>< _ BOD (5 day) __ Cyanide __ Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium Zinc I 1 _ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOs __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*^ GLE f 1 _ Metals/CN __ Dissolved Oxygen __ Nitrogen, Nitrate as N __ Chromium, Total I __ Total Organic Carbon __ Volatiles 1 __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Total Organic Halides __ Semi-vtolatiles __ Nitrogen, Total Kjeldahl as N __ Cobalt __ Pesticides/PCB's __ Solids, Percent (%) __ Oil and Grease __ Copper I __ Solids, Settleable __ Phenol __ Iron 1 __ Solids, Suspended . __ Phosphorus Total as P __ Lead I£i£ _TCLP-Metals 1 ?;■ __ 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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