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 (914) 231-1620 Fax (914) 231-1772 <1 Pl

NYS-ELAP No. 10108 I Time/Date Set: Form A-70 (rev. 10/01)

Sample Type (circle one): C- 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: Location's/lndividual's Name Name/Company Street_________________ Street_________ City/St/Zip______________ City/St/Zip I Identification of Source Phone#: Fax#: Collection Point *’ CA,CH, Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:_______________________ I ORGANIC POTABLE ANALYSIS ORGANIC NON POTABLE/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) ’ 1 __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SMI8/6630) _ API •'i __ 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) r- __ 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 ___________ t¥> _UCMRList 1 RADIOCHEMICAL ANALYSIS _MtBEOnly (524) 1. __ Radon __ Other

INORGANIC ANALYSIS REQUESTED - Lab#: / __ Color __ /k: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 CaCOa __ Calcium, as CaCOa CLP __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*^ _ Metals/CN __ Dissolved Oxygen __ Nitrogen, Nitrate as N _ Chromium, Total I __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Volatiles __ Semi-violatiles I __ Total Organic Halides __ Solids, Percent (%) __ Nitrogen, Total Kjeldahl as N __ Oil and Grease __ Cobalt __ Copper __ Pesticides/PCB’s __ Solids, Settleable __ Phenol __ Iron ICLP __ 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 I

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