Chain of Custody Record, Samples AE03434/3454, Feb 2002

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM AVestchester WESTCHESTER COUNTY LABORATORIES AND RESEARCH gov.com 2 Dana Road, Valhalla, New York 10595 (914) 231-1620 Fax (914) 231-1772 id Of* I

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 t Chain of Custody? Yes___ No Time/Date Collected: ; vv \\ X Comments: Collected By: t '\ 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 CA,CH. Bl? Check#: Amounts

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:_______________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count __ Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) (hemodialysis & all others) __ 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) __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SMI8/6630) _ API __ 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) _1'-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 (SMI 8/6630) pH ___________ __ UCMR List 1 RADIOCHEMICAL ANALYSIS _ MtBE Only (524) __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Acidity -Aluminum __ Potassium __ Turbidity __ Alkalinity Antimony _i-Selenium _ pH __ Bromide Arsenic -Silver __ Conductivity __ Bromate/Chlorate/Chlorite YL Barium __ Sodium __ Corrosivity (temp:. .°C) __ Chloride Beryllium Thallium _ BOD (5 day) __ Cyanide __ Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium _irZinc _ 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 JiiiChromium, Total _ Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Sem i-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 _ TCL P-Volatiles / Other: x _ UV254 _ ; Molybdenum _ TCLP-BNA’s __ Nickel

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