Chain of Custody Record, Sample AE03471, Feb 2002

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 o/l 1 o/ ■ I s* M.I X (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 .Votable 3. Non Potable Treated Bottle #'s: '>■ ‘ > s 2. Non Potable 4. Other____________ Chain of Custody?___ Yes No Time/Date Collected: Comments: Collected By: V V' i Agency Code: PWS #:______ Type Descriptor: Source ID: 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 (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) __ 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 (SMI 8/6630,8151) _ API __ PCB as Decachlorobiphenyl (508A) Other Pesticides^(SM 18/6630) __ 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) 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 (SMI8/6630) pH ___________ _UCMRList 1 RADIOCHEMICAL ANALYSIS _MtBE Only (524) Radon - i __ Other____________________ 7 "" ) INORGANIC ANALYSIS REQUESTED - Lab#; / __ Color __ /V:idity __ Aluminum __ Potassium __ 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 CaCOs __ 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 T.CLP __ 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 t- __ Solids, Total Volatile __ Surfactants __ Mercury __ TCLP-Volatiles __ Other:_____ :___________ UV254 __ Molybdenum _ TCLP-BNA’s __ Nickel

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