Chain of Custody Record, Sample AE03471, Feb 2002

NYC 9/11 Public Portal Document

ACOd ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH 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): - /, 74:7 1. Potable 3. Non Potable Treated Bottle #’s:

2. Non Potable 4. Other Chain of Custody?Yes No Time/Date Collected: ; 11--I 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 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) __ 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) i __ Macroscopic __ Pesticides/PCB screen (508) __ Herbicides (SM18/6630,8151) _ API __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SMI8/6630) __ 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 _____________ _UCMR List 1 RADIOCHEMICAL ANALYSIS _MtBEOnly (524) ___ Radon __ Other_______________________ t INORGANIC ANALYSIS REQUESTED - Lab#: 1 __ Color __ Acidity t-Aluminum __ Pr^tassium __ Turbidity __ Alkalinity Antimony _h''Se7enium _ pH __ Bromide T "Arsenic '--^silver __ Conductivity __ Bromate/Chlorate/Chlorite _ii''Barium __ Sodium I __ Corrosivity (temp:. °C) __ Chloride j:::2^Beryi;ium _^-Thallium _ BOD (5 day) __ Cyanide __ Boron _ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride _ Cadmium j-r^Zinc _ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOs CLP __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca+2 __ Dissolved Oxygen 2r;Chromium, Total _Metals/CN __ Nitrogen, Nitrate as N __ 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 _i 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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