Chain of Custody Record, Sample AE03802, Feb 2002

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM v ' ‘ ster ! 1v.coin: WESTCHESTER COUNTY LABORATORIES AND RESEARCH

2 Dana Road, Valhalla, New York 10595 z .

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(914) 231-1620 Fax (914) 231-1772 /NYS-ELAP No. 10108 Time/Date Set: Form A-70(rev.10/01) ■ - ■ ■ - ‘ ■? ■-•■■■ ........................... •

Sample Type (circle one):

I UPotable 3. Non Potable Treated Bottle #’s?:______ ? ......’ Y__________ ________________

2. Non Potable 4. Other Chain of Custody?___ Yes No T:mo.'DYo Cn'leclori- ........ "''.(..A. ... ______J ■■■■■■ Contmonts: Collected By:;1 Agency Code: PWS #■ ... .... Sourr.-'ID' Type Di'sciipbir: Coliecteti From. Location's/lndividuai's Name Name/Company____ _ __________ _ ______ ______________________ Street __ /________ ______ ____ Street_________________ ____________________ City/St/Zip_ 2_ ______ _Y______ ___________ . ’ C.. -- J identification of Source__________________________ Phone#: _ Fax#; Collection Point j___ _____________________ I CA,CH, Bl? „ Check#; .. Amounts.

■ I □ACTERIOLOGICAl. .ANALYSIS Lab#; Lab#:_____________ _______ _ ____ _ __ Heterotrophic Plate Count ORGANIC POTABLE. ANALYSIS ORGANIC NONPOrABl.E.'SOLID ANALYSIS I■ __ Trihaiomethanes (524) __ Purgeabie Halocarbons (624/8260) (hemodialysis & all others) Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) ___ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) __ Fecal Coliform (all samples) Volatile Aromatics (524) __ Total Trihaiomethane Potential (510) __ Acrolein & Acrylonitrile (8260) __ Organochiorine Pesticides (608/8081) i __ Microscopic __ Macroscopic API __ Microextractabies (504) __ Pesticides/PCB screen (508) __ PCB as Decachlorobiphenyl (508A) _ PCB’s (Arochlors) (608/8081) __ Herbicides (SM19/6630,8151) ...... Other Pesticides (SM18/6630) * I __ Other:___________ ____________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13)

Refrigerated?yes no __ Pesticides (525) __ Carbamate Pesticides (531) __ Glycols in Water __ Acid Extractables (625/8270) Hi ■ Chlorinated:? yes___ no __ Glyphosate (547) ..... Base Neutral Extractables (625/8270) ■ ^Diquat (549) GC/MS Unknown Scan Free Chlorine Res:mg/L Total Chiorine Res:mg/L __ Chlorination Disinfection Byproducts (551) __ Haloacetic Acids (552) „ Other Pesticides (SM18/6630) Phthalates (606MS) _ Other;___________________________ ■ pH--------------------- _UCMRList1 MtBE Only (524) ■ RADIOCHEMICAL ANALYSIS: ___ Radon __ Other: IB: INORGANIC ANALYSIS REQUESTED - l..il.#:i - I ' __ Color __ Acidity jS Aluminum __ Potassium _ Turbidity __ Aikaiinity Antimony __ Selenium __ pH __ Bromide .21Arsenic Silver Conductivity __ Bromate/Chlorate/Chlorite _i;-Barium __ Sodium _ Corrosivity (temp;______ °C) __ Chloride Beryllium .jm Thallium _ BOD (5 day) __ Carbonaceous BOD (5 day) __ Cyanide __ Fluoride __ Boron _j;Cadmium __ \A3nadium .■Zinc ■ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOs Chemical Oxygen Demand __ Dissolved Oxygen __ Nitrogen, Ammonia as N __ Nitrogen, Nitrate as N __ Calcium, Ca*2 Metal-A'CN ■ ../^Chromium, Total __ Volatiles __ Total Organic Carbon Total Organic Halides __ Nitrogen, Nitrite as N __ Nitrogen, Total Kjeldahl as N; __ Chromium, Hexavalent: _£’Cobalt __ Semi-violatiles I Solids, Percent (%) Po};iitxi1es/HGB‘;;: __ Oil and Grease ..iGopper __ Solids, Settleable __ Phenol _jfc4ron tclp ._ Solids, Suspended __ Solids, Total __ Phosphorus Total as P __ Phosphorus, Ortho as P _..j,-Lead __ Magnesium _.TCLP-Metals I __ TCLP-Pesticides Solids, Total Dissolved __ Sulfates __(Manganese __ Solids, Total Volatile _TCLP-Herbicides __ Surfactants mMercury TCi.PVolaliie;: __ ,--Other: ■ i __ UV254 fr "Molybdenum __ TCLP-BNAs ^■Nickel

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