Chain of Custody Record, Sample AE03730, Feb 2002

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH 4 2 Dana Road, Valhalla, New York 10595 JX (914) 231-1620 Fax (914) 231-1772 NYS-ELAP No. 10108 Time/Date Set: Form A-70 (rev. 10/01) '/ I I I Sample Type (circle one): 1. Potable 3. Non Potable Treated Bottle #'s: 2. Non Potable 4. Other_____ ______ I » Chain of Custody? Yes___ No J Time/Date Collected; Comments:

1 Collected By: \ A k Agency Code: PWS #:________ Source ID: Type Descriptor: Collected From: \ Bill to: I Location’s/lndividual’s Name Name/Company I Street_________________ Street_________ City/St/Zip______________ City/St/Zip I I Identification of Source Phone#:_______ Fax#: Collection Point I CA,CH, Bl? Check#: Amounts

! Lab#: BACTERIOLOGICAL ANALYSIS I Lab#:_______________________ ! ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count __ Purgeable Halocarbons '(624/8260) I (hemodialysis & all others) __ Trihalomethanes (524) __ Coliform P/A (Public supplies) __ Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform MPN (priv well, raw, stp) __ Volatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) __ Fecal Coliform (ail 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) I __ 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 (SMI8/6630) pH ---------------- --- RADIOCHEMICAL ANALYSIS __ Radon __ Other____________________ __ UCMR List 1 _MtBEOnly (524) J •■'ti

INORGANIC ANALYSIS REQUESTED - Lab#: f- __ Color __ Acidity ‘-^Aluminum __ Potassium . __ Turbidity __ Alkalinity Antimony jrrr'Selenium . j "t _ pH __ Bromide ^.Arsenic 2±'Silver / f?- __ Conductivity __ Bromate/Chlorate/Chlorite Barium __ Sodium __ Corrosivity (temp:. °C) __ Chloride ^-Beryllium A^-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 CLP __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*2 _ Metals/CN __ Dissolved Oxygen __ Nitrogen, Nitrate as N ._zChromium, Total ' __ Volatiles __ Total Organic Carbon __ Total Organic Halides __ Solids, Percent (%) __ Nitrogen, Nitrite as N __ Nitrogen, Total Kjeldahl as N __ Oil and Grease __ Chromium, Hexavalent _!_.c6balt '-'Copper __ Semi-violatiles __ Pesticides/PCB’s J __ Solids, Settleable __ Solids, Suspended __ Solids, Total __ Phenol __ Phosphorus Total as P __ Phosphorus, Ortho as P "Iron Lead __ Magnesium TCLP _TCLP-Metals 1 __ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates Manganese __ TCLP-Herbicides __ Solids, Total Volatile __ Surfactants _ ; Mercury _ TCLP-Volatiles ..--other: _ UV254 Molybdenum I _ TCLP-BNA’s __ .Nickel 4

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