Chain of Custody Record, Sample AE03730, Feb 2002

NYC 9/11 Public Portal Document I

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ;, J^stehester WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914) 231-1620 Fax (914) 231-1772 ya .I NYS-ELAP No. 10108 Time/Date Set; Form A-70 (rev.10/01) r f Sample Type (circle one): y A Bottle #'s: / i 1. Potable 3. Non Potable Treated I 2. Non Potable 4. Other Chain of Custody?___ Yes No A Time/Date Collected: Comments:__________________ I Collected By: •' - Agency Code; PWS #: Source ID: Type Descriptor: 1 Collected From: Bill to; i Location’s/lndividual’s Name Name/Company Street Street_______ City/St/Zip_________ City/St/Zip Identification of Source. Phone#: Fax#: I A S Collection Point ii #3 CA,CH, Bl? Check#: Amount$_L I BACTERIOLOGICAL ANALYSIS Lab#: Lab#:_______________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count . Purgeable Halocarbons (624/8260) (hemodialysis & all others) __ Trihalomethanes (524) I __ Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) I __ 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) 1 I __ Fecal Coliform (all samples) __ Microscopic __ Microextractables (504) _ PCB’s (Arochlors) (608/8081) ' I __ Macroscopic _ API __ Pesticides/PCB screen (508) __ PCB as Decachlorobiphenyl (508A) _ Herbicides (SM18/6630,8151) __ Other Pesticides (SMI8/6630) __ Other:____________________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) ’v __ 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) __ 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 ___________ _UCMRList 1 RADIOCHEMICAL ANALYSIS _MtBEOnly (524) 1 '1 __ Radon __ Other_____________ _______

INORGANIC ANALYSIS REQUESTED - Lab#. __ Color __ Acidity __ Aluminum __ Potassium’ ^1 __ Turbidity __ Alkalinity Antimony __ Selenium _ pH __ Bromide __ Arsenic __ Silver __ Conductivity __ Bromate/Chlorate/Chlorite Barium __ Sodium __ Corrosivity (temp:. °C) __ Chloride __ Beryllium __ Thallium _ BOD (5 day) __ Cyanide __ Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Zinc t __ Soluble BOD (5 day) __ Chemical Oxygen Demand __ Hardness, Total as CaCOs __ Nitrogen, Ammonia as N __ Calcium, as CaCOa __ Calcium, Ca*2 CLF 3 'a _ Metals/CN __ Dissolved Oxygen __ Nitrogen, Nitrate as N __ Chromium, Total __ Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Semi-violatiles __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N __ Cobalt __ Pesticides/PCB’s __ Solids, Percent (%) __ Solids, Settleable Solids, Suspended __ Oil and Grease __ Phenol __ Phosphorus Total as P __ Copper __ Iron __ Lead TCLP _TCLP-Metals a __ Solids, Total __ Phosphorus, Ortho as P __ Magnesium __ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates __ Manganese __ TCLP-Herbicides __ Solids, Total Volatile __ Surfactants __ Mercury __ TCLP-Volatiles __ Other: -_____________ __ UV254 __ Molybdenum _ TCLP-BNA's __ Nickel

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