Chain of Custody Record, Sample AE03503, Feb 2002

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ^^ovcom WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 s/neHfSt NYS-ELAP No. 10108 Time/Date Set: Form A-70 (rev. 10/01) a 2~75A(7 Zb6Q Sample Type (circle one): p - so V*' '61/ fl^otable 3. Non Potable Treated Bottle #’s: Zr/3 Y'/ 3S 7 l/ ‘2 0:7 Z 2c(?

2. Non Potable 4. Other j Chain of Custody?___ ,Yes___ No k 2.07 Time/Date Collected:__________________ I < ' o 2... Comments:: Collected By:_ t <1. r/ Agency Code: ‘ PWS #:______ Source ID; Type Descriptor: Collected From: V Bill to: / Location's/lndividual’s Name. Name/Company Street I1 N r ( rt Street_______ City/St/Zip y-irTij/i i uV r City/SVZip Identification of Source Phone#: Fax#: Collection Point ( f-J-i CA,CH, Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:_______________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count (hemodialysis & all others) __ Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) je^Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) ■ ^^olatile 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) _ 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:mg/L __ Haloacetic Acids (552) __ Other;____________________________ __ Other Pesticides (SM18/6630) pH ------------------- __ UCMR List 1 RADIOCHEMICAL ANALYSIS _ MtBE Only (524) __ Radon __ Other_____________________

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Acidity jXAIuminum __ potassium __ Turbidity __ Alkalinity >^ntimonv iZSelenium _ pH __ Bromide jZArsenic jZsilver ; __ Conductivity __ Bromate/Chlorate/Chlorite ./Barium __ Sodium i __ Corrosivity (temp:. .°C) __ Chloride x/Beryllium uZrhallium j _ BOD (5 day) __ Cyanide __.Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride /Cadmium Zinc I _ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOa __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*2 £LP -■ /chromium. Total __ Metals/CN __ Dissolved Oxygen __ Nitrogen, Nitrate as N __ Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent .h/obalt __ Semi-violatiles __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N j/opper __ Pesticides/PCB’s __ Solids, Percent (%) __ Oil and Grease __ Solids, Settleable __ Phenol /ron TCLP __ Solids, Suspended __ Phosphorus Total as P t/ead _TCLP-Metals __ Solids. Total __ Phosphorus, Ortho as P __ ^gnesium jc^anganese __ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates __ TCLP-Herbicides Solids, Total Volatile __ Surfactants i yMercury Other: _SlO___________ _ TCLP-Volatiles _ UV254 i/Molybdenum _ TCLP-BNA’s I

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