Chain of Custody Record, Sample AE03822, Feb 2002

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTYXaBORATORIES AND RESEARCH i F 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 * 1 -- o BSI * St ’ NYS-ELAP No",10108 / Time/Date Set: fY ■ - Form A-70 (rev. 10/01)"^ I'" ■ ‘vtt,.' IS so, fc is Sampl^ Type (circle one): (j^Potabl^ 3. Non Potable Treated Bo«le#.s:__5L2«/L 2. Non Potable 4. Other_______________________ :______ Chain of Custody? 'Yes >. No •

i Time/Date Collected: Comments: > / / ■ Collected By: t'A ■ o •4 Va Agency Code: PWS #: Source ID: -■Type Descriptor: Collected From: Bill to:

I ' Location's/lndividual’s Name Street_____ ,___________ Name/Company Street ' •I **

I ■;City/St/Zip______________ Identification of Source City/St/Zip Phone#: h-’‘ ; Fax#: i 1+ , Sr 1 is Collection Point CA,CH, Bl? Check#: Amounts.

fc: BACTERIOLOGICAL ANALYSIS Lab#: / /// -O’ '( '• i, :3

Lab#: - _______ ORGANIC POTABLE ANALYSIS / • ORGANIC NONPOTABLE/SOLID ANALYSIS ; Heterotrophic Plate Count __ Trihalomethanes (524) ' " - Purgeable Halocarbons (624/8260) Z (hemodialysis & all others) __ Volatile Halocarbons (524) * _ Purgeable Aramatics (624/8260) ■’/• is?"' :_ Coliform P/A*' (Public supplies) __ Volatile Arorpatics. (524) i ; _ Acrolein & Acrylonitrile (8260) * , j. i Zj, Coliform MPN (priv well, raw, stp)

g -'_j.«Fecal Coliform' (all samples) __ Microscopic __ Total Trihalomethane Potential (510) __ Microextractables (504) J '__ -Organochlorine Pesticides (608/80'81) , _ PCB's (Arochlors) (608/8081) ’

r __ Macroscopic ■ __ Pesticides/PCB screen (508) _ Herbicides (SMI8/6630,8151) . ^API. __ PCB as Decachlorobiphenyl (508A) _‘Other Pesticides'(SMI8/6630) ' ' _j.- Other: 2___________________ __ Herbicides (515) , ■ , . Petroleum'Hydrocarbon Scan (310-,13) __ Pesticides (525) • ' « '__ Glycols in Water) ? " ' j' Refrigerated?yes___ no _ Carbamate Pesticides (531) ' =_ Acid Extractables ’(625/8270) Z ?v, __ Glyphosate (547) ? Base Neutral Extractables (625/8270)' X Chlonnated:?yes 2__ no _ Diquat (549) J/ GC/MS Unknown Scan * ///'■-’ " - Z." Free Chlorine Res:mg/L Si Totai'Chlorine Res:mg/L _ Chlorination Disinfection Byproducts (551) __ Haloacetic Acids (552) '■ • _ Phthalates (606MS) • ‘ _ Other: ,/ __ Other Pesticides (SM18/6630) ' t & s _UCMRList1 5 .RADIOCHEMICAL ANALYSIS MtBE Only (524) - Radori I' is SZ other _______ L__Z_____ ’

INORGANIC ANALYSIS REQUESTED - Lab#: ’” S" 'Si 6«' Color' J . __ /Acidity Y Alurhinum ■__ Potassium^ = . » I. Turbidity ’ _ Alkalinity ,• 7 Antimony ■ j/Seleniurh I' :

I X'PH __ Conductivity Brorhide „ .__ Bromate/Chlorate/ChForite vZArsenic v^arium, ! *' -ZZ Silver / X _ Sodium "T . 1 i _ Corrosivity (temp :____“C) ‘__ Chloride JiZBeryllium j/ThalliurpY - ±_ BOD (5 day) __ Cyanide __ Boron f,, ' Vanadium/ _ s" “ Carbonaceous BOD*'(5 day)' I_ Fluoride __ Cadrhium □Zzincj '■/ ! __ Soluble BOD (5 day) :_ Hardness, Total as CaCOs __ Calcium', as CaCOa CLP - ~ -__ Chemical Oxygen Demand _/ Dissolved Oxygen L_ Nitrogen, Ammonia as N __ Nitrogen, Nitrate as N Calcium,'Ca+2 ' " jZchromium, Total _Metals/CN ' ; *• " 1 __ Total Organic Carbon Volatiles. . ' __ Nitrogen, Nitrite as N _ ; Chromium, Hexavalent /_ Total Organic Halides ■/Cobalt' " ' ' Semi-violatiles > ■ Nitrogen, Total Kjeldahl as N _ Solids, Percent (%) 2 Copper _ Pesticides/PCB’s ' __ Oil and Grease

k r' _ Solids,’Settleable '__ Solids,Suspended _ Solids, Total __ Pheriol __ Phosphorus Total as P __ Phosphorus, Ortho as P ‘ Ji/Iron jZ Lead __ Magnesium *■ s ’ ■ - tclp <_TCLP-Metals. 1 i I/" _ Solids, Total Dissolved __ Solids, Total Volatile __ Sulfates ' Surfactants j/.Manganese './Mercury T TCLP-Pesticides ‘ __ TCLP-Herbicides

fe'fc Other: ___________ _'UV254

.... . ■ ' - sZ Molybdenum J/Nickel _ TCLP-Volatiles _TCLP-BNA’s-

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