Chain of Custody Record, Sample AE03611, Feb 2002

NYC 9/11 Public Portal Document

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. 16-108 J Time/Date Set: Form A-70 (rev. 10/01)

Sample Type (circle one): - -2 t - 7 r' - i r VY 1. Potable 3. Non Potable Treated Bottle #’s:

2. Non Potable 4. Other________ ______ Chain of Custody?___ Yes No Time/Date Collected: Comments: Collected By: ->• Agency Code: PWS #:_______ Source ID: Type Descriptor: Collected From: Bill to: Location’s/lndividual’s Name Name/Cornpany i Street____________________ Street_________ City/SVZip________________ City/St/Zip Identification of Source Phone#: Fax#: j- I Collection Point CA,CH, Bl? Check#: Amounts. " i 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) __ 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 1 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)

I Total Chlorine Res: pH -_____________

RADIOCHEMICAL ANALYSIS . mg/L __ Haloacetic Acids (552) __ Other Pesticides (SMI8/6630) _UCMRList 1.. _ MtBE Only (524) ' __ Other:________ _____________________

I ___ Radon __ Other_______________________

/ ■ I INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Acidity ’-'Aluminum __ Potassium __ Turbidity __ Alkalinity ^Antimony Selenium _ pH __ Bromide ^Arsenic ^■Silver __ Conductivity __ Bromate/Chlorate/Chlorite ‘•'Barium __ Sodium __ Corrosivity (temo: °C) __ Chloride _^Beryllium j_-TKallium _ BOD (5 day) __ Cyanide __ Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium <-Zinc _ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOa __ Chemical Oxygen Demand CLP __ Nitrogen, Ammonia as N __ Calcium, Ca*2 __ Dissolved Oxygen J:rCfiromium, Total _Metals/CN ’ __ Nitrogen, Nitrate as N ___ Total Organic Carbon __ Volatiles __ Nitrogen, Nitrite as N __ -Chromium, Hexavalent __ Total Organic Halides __ Semi-violatiles __ Nitrogen, Total Kjeldahl as N Cobalt _ Solids, Percent (%) __ Pesticides/PCB’s __ Oil and Grease Copper __ Solids, Settleable __ Phenol I " Iron TCLP __ Solids, Suspended __ Phosphorus Total as P ,_L*Lead . __ Solids, Total _TCLP-Metals __ Phosphorus, Ortho as P __ Magnesium __ Solids, Total Dissolved __ TCLP-Pesticides _ Sulfates _L-'Manganese __ Solids, Total Volatile __ TCLP-Herbicides __ Surfactants *--Mercurv _5^^0fher: _ TCLP-Volatiles _ UV254 _L'Molybdenum _2'NTckel _ TCLP-BNA’s

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