Chain of Custody Record, Sample AE03471, Feb 2002

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM Westchester WESTCHESTER COUNTY LABORATORIES AND RESEARCH ■/ govcom 2 Dana Road, Valhalla, New York 10595 o /■ 1 A IC. (914) 231-1620 Fax (914) 231-1772 e tqV, NYS-ELAP No. 10108 Time/Date Set: Form A-70 (rev.10/01) i !

Sample Type (circle one): f 1. Potable 3. Non Potable Treated Bottle #'s: 2. Non Potable 4. Other f Chain of Custody?___ Yes No 1 Time/Date Collected: Comments: Collected By: A2 k21 LJ^_Agency Code: PWS #: Source ID: Type Descriptor: t 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) (hemodialysis & all others) __ Purgeable Halocarbons (624/8260) __ Coliform P/A (Public supplies) __ Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform MPN (privwell, raw, stp) __ Volatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) t __ 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) _ 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 (SM18/6630) pH _UCMRList 1 RADIOCHEMICAL ANALYSIS _MtBEOnly (524) __ Radon __ Other____________________

f INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Acidity Is Aluminum __ Potassium __ Turbidity __ Alkalinity ^-•'Antimony - Selenium _ pH __ Bromide Arsenic ^'Silver __ Conductivity __ Bromate/Chlorate/Chlorite Barium __ Sodium __ Corrosivity (temp:. °C) __ Chloride '■. -- Beryllium _:l''Thallium __ BOD (5 day) __ Cyanide __ Boron __ Vanadium ? __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium —■ Zinc _ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOs __ Chemical Oxygen Demand CLP __ Nitrogen, Ammonia as N __ Calcium, Ca*2 __ Dissolved Oxygen __ Nitrogen, Nitrate as N SSChromium, Total _ Metals/CN __ Total Organic Carbon __ Volatiles __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N __ Semi-violatiles Cobalt __ Solids, Percent (%) __ Pesticides/PCB’s __ Oil and Grease Copper __ Solids, Settleable __ Phenol Iron TCLP __ Solids, Suspended __ Phosphorus Total as P Lead __ Solids, Total _TCLP-Metals __ Phosphorus, Ortho as P __ Magnesium __ Solids, Total Dissolved __ TCLP-Pesticides __ Sulfates _r: Manganese __ Solids, Total Volatile __ Surfactants __ TCLP-Herbicides -- Mercury __/Other:< .a __ TCLP-Volatiles _ UV254 __ Molybdenum _ TCLP-BNAs _ -Nickel

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