Chain of Custody Record, Sample AE03730, 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 4 o/ ■ I

NYS-ELAP No. 10108 Time/Date Set: Form AYO (rev.10/01)

Sample Type (circle one): ft

‘ 1. Potable 3. Non Potable Treated Bottle #’s: 2. Non Potable 4. Other___________ Chain of Custody?___ Yes No Time/Date Collected: -........>■ :

Comments; "1 '1 Collected By: ■' ’ Agency Code: PWS #:______ Source ID: Type Descriptor: Bill to; I Collected From: f Location’s/lndividual.’s Name Name/Company Street________________ _ Street_______ City/St/Zip______________ City/St/Zip 4 Identification of Source Phone#: Fax#; Collection Point solid CA,CH, Bl? Check#: Amounts

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) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081) ,*5 __ Fecal Coliform (all samples) __ Microextractables (504) _ PCB’s (Arochlors) (608/8081)' __ Microscopic __ Pesticides/PCB screen (508) _ Herbicides (SMI8/6630,8151)' s __ Macroscopic A _ 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)' 1 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'(SMI 8/6630) pH ------------------- _UCMR List 1 >4 RADIOCHEMICAL ANALYSIS _MtBE Only (524) __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#; '^'1 __ Color __ /Acidity Aluminum ' __ Potassium __ 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 4 __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Zinc _ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOa ■CLP __ 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 __ Nitrogen, Total Kjeldahl as N __ Cobalt __ Pesticides/PCB’s __ Solids, Percent (%) i__ Solids, Settleable __ Oil and Grease __ Phenol , __ Copper ' __ Iron TCLP t .1 __ Solids, Suspended __ Phosphorus Total as P Lead. -' _TCLP-Metals __ Solids, Total __ Solids, Total Dissolved __ Solids, Total Volatile __ Phosphorus, Ortho as P __ Sulfates __ Surfactants __ Magnesium • __ Manganese __ Mercury \ ' __ TCLP-Pesticides _TCLP-Herbicides I J _ TCLP-Volatiles __ Other:_______ ::_________ _ UV254 __ Molybdenum _TCLP-BNA’s ’ _ Nickel

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