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 2 Dana Road, Valhalla, New York 10595 ^4 Till (914)231-1620 Fax (914) 231-1772

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

Sample Type (circle one): \ VILx- 1. Potable 3. Non Potable Treated Bottle #’s:

2. Non Potable 4. Other___________ ■ ■I Chain of Custody? Yes No Time/Date Collected: p. Comments: Collected By; ■Q' Agency Code: PWS #:_________ Source ID: Type Descriptor: Collected From: Bill to:

Location’s/lndividual’s Name Name/Company Street____________________ Street__________ i 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) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081) __ Fecal Coliform (all samples) ! __ Microscopic __ Microextractables (504) __ PCB’s (Arochlors) (608/8081) __ Pesticides/PCB screen (508) i? __ Macroscopic __ PCB as Decachlorobiphenyl (508A) _ Herbicides (SM18/6630,8151) _ 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 Extractabies (625/8270) Chlorinated:? yes___ no __ Glyphosate (547) __ Base Neutral Extractabies (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.J_______________________ ______ _Other Pesticides (SM18/6630) pH _____________ _UCMRList1

I , RADIOCHEMICAL ANALYSIS _MtBEOnly (524) ___ Radon __ Other_______________________

INORGANIC ANALYSIS REQUESTED - Lab#: / b __ Color __ Acidity '<2. Aluminum __ Potassium __ Turbidity __ Alkalinity '"^Antimony _r'Selenium * _ pH __ Bromide '-12. Arsenic Silver __ Conductivity __ Bromate/Chlorate/Chlorite ■'•’21.Barium __ Sodium __ Corrosivity (temp:. °C) __ Chloride Beryllium ^-■Thallium' _ BOD (5 day) __ Cyanide __ Boron __ Vanadium !*. __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium 1 ..'Zinc _ 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 jjlChromium, Total i. __ Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Semi-violatiles __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N l^Cobalt __ Pesticides/PCB’s __ Solids, Percent (%) __ Oil and Grease Copper __ Solids, Settleable __ Phenol jx'lfon TCLP 1 __ Solids, Suspended __ Solids, Total __ Phosphorus Total as P __ Phosphorus, Ortho as P ir'Lead _ Magnesium _TCLP-Metals __ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates Manganese .Y __ TCLP-Herbicides _ Solids, Total Volatile __ Surfactants -'"Mercury i±<6ther: _ TCLP-Volatiles _ UV254 j::!. Molybdenum A _ TCLP-BNA's __ Nickel

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