Chain of Custody Record, Sample AE03730, Feb 2002

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH I ’asdsisp 2 DanaiR6ad, yalHalla,-New York 10595 /I I IS 3C ' 231-1772 NYS-ELAP No. 10108 ! Time/Date Set: Form A-70 (rev. 10/01) I I Sample Type (circle one): i- „ ..-C-

1. Potable 3. Non Potable Treated •:: s.---------------------------------- 2. Non Potable 4. Other___________ t ^--'i^^Chain of Custody?Yes No Time/Date Collected: * Comments:__________________ Collected By:____________ Agency Code: PWS #: Source ID: Type Descriptor: Collected From: Bill to: Location’s/lndividuaTs Name Name/Company Street_________________ Street City/St/Zip______________ City/St/Zip Identification of Source Phone#: Fax#: Collection Point CA,CH, Bl? Check#: Amounts ■

BACTERIOLOGICAL ANALYSIS Lab#; I Lab#:_______________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS ’ 'Y __ Heterotrophic Plate Count (hemodialysis & all others) __ Trihalomethanes (524)^ __ Purgeable Halocarbons (624/8260) __ 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 (all samples) __ Total Trihalomethane Potential (510) __ ■ Organochlorine Pesticides (608/8081) ' .4 __ 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 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) ■4 Total Chlorine Res: mg/L __ Haloacetic Acids (552) __ Other:____________________'_______ pH ___________ _ Other Pesticides (SM18/6630) _UCMRList 1 fl RADIOCHEMICAL ANALYSIS _MtBE Only (524) I __ Radon __ Other____________________ _l ■ .':S

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Turbidity _ pH __ Acidity __ Alkalinity __ Bromide __ Aluminum __ Antimony __ Arsenic __ Potassium __ Selenium. __ Silver . ' J I 1I __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium' • ’ / __ Corrosivity (temp:. _ BOD (5 day). __ Carbonaceous BOD (5 day) °C) __ Chloride __ Cyanide __ Fluoride __ Beryllium __ Boron __ Cadmium __ Thallium __ Vanadium Zinc ’ j 'Yi _ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOs “CLP ‘a __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*2 _ 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 __ Solids, Percent (%) __ Solids, Settleable __ Nitrogen, Total Kjeldahl as N __ Oil and Grease __ Phenol _ Cobalt , Copper __ Iron __ Pesticides/PCB’s

TCLP 4 __ Solids, Suspended __ Solids, Total __ Solids, Total Dissolved __ Phosphorus Total as P __ Phosphorus, Ortho as P __ Sulfates __ Lead __ Magnesium __ Manganese _TCLP-Metals __ TCLP-Pesticides 1 __ Solids, Total Volatile __ Surfactants __ Mercury __ TCLP-Herbicides ■1 _ TCLP-Volatiles _ir^dther: _ UV254 __ Molybdenum _ TCLP-BNA’s ,_ Nickel '•i

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