Chain of Custody Record, Sample AE03503, Feb 2002

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM AZestchester WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 < ' ■ . "Trr TiiW* ' X (914)231-1620 Fax (914) 231-1772 NYS-ELAP No. 10108 Time/Date Set: Form A-70 (rev. 10/01) ■ i / vucj.’t ■? Saj^je-Typ.e jcircle one); i.i / I I d. Potabie^. .5 3. Non Potable Treated Bottle #’s: J

2. Non Potable 4. Other Chain of Custody? _ Yes___ No Time/Date Collected: _JJJJJjJ12^jJjjJ/JjJ). Comments; Collected By; D - <571 Agency Code; PWS #:________ Source ID: Type Descriptor: Collected From: __ _ Bill to: Location’s/lndividual’s Name f' '4 ' * Name/Company Street Street_________ City/St/Zip Citv/St/Zio Identification of Source_______________________ Phone#;_______ Fax#: Collection Point / ,XV--T~ / J-, {- 'f CA,CH, Bl? Check#; Amounts.

BACTERIOLOGICAL ANALYSIS Lab#; 1 Lab#:_______________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count (hemodialysis & all others) __ Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) _zSVolatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) ^y^olatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) __ Coliform MPN (priv well, raw, stp) __ 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 (SM18/6630) _ 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) J<^GC/MS Unknown Scan Free Chlorine Res: . mg/L __ Chlorination Disinfection Byproducts (551) __ Phthalates (606MS) Total Chlorine Res: . rng/L __ Haloacetic Acids (552) __ Other:____________________________ _ Other Pesticides (SM18/6630) pH ___________ _UCMRList 1 RADIOCHEMICAL ANALYSIS _ MtBE Only (524) __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: . / I

__ Color __ Acidity Aluminum __ Potassium __ Turbidity __ Alkalinity >£ Antimony Selenium _ pH __ Bromide V Arsenic Silver __ Conductivity __ Bromate/Chlorate/Chlorite hC Barium __ Sodium ’ __ Corrosivity (temp:. .“C) __ Chloride Beryllium Ji, Thallium ( _ BOD (5 day) __ Cyanide __ Boron __ Vanadiumj __ Carbonaceous BOD (5 day) __ Fluoride XCadmium Zinc ( _ Soluble BOD (5 day) __ Hardness, Total as CaCOs _ Calcium, as CaCOa CLE ■ ’__ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*2 __ Dissolved Oxygen __ Nitrogen, Nitrate as N _ Metals/CN ^'Chromium, Total __ Total Organic Carbon __ Volatiles i __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Total Organic Halides __ Semi-violatiles __ Nitrogen, Total Kjeldahl as N 2L Cobalt __ Solids, Percent (%) __ Pesticides/PCB's __ Oil and Grease Ji Copper __ Solids, Settleable __ Phenol Jl Iron TCLP __ Solids, Suspended __ Phosphorus Total as P YLead __ Solids, Total _TCLP-Metals __ Phosphorus, Ortho as P __ Magnesium __ Solids, Total Dissolved __ TCLP-Pesticides __ Sulfates Ji Manganese __ Solids, Total Volatile __ TCLP-Herbicides __ Surfactants Ji Mercury '2^ Other: Ji Molybdenum _ TCLP-Volatiles _ UV254 _ TCLP-BNA’s Jx Nickel

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