Chain of custody record, Westchester County Lab, Feb 2002

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH di 2 Dana Road, Valhalla, New York 10595 1 (914) 231-1620 Fax (914) 231-1772 X

NYS-ELAP No. 10108' Time/Date Set: Form A-70 (rev. 10/01)

Sample Type (circle one): (1y Potable . 3. Non Potable Treated Bottle r.t 2. Non Potable 4. Other______________ __________ Chain of Custody? Yes No Time/Date Collected: _ Comments: Collected By: Agency Code: PWS #:________ Source ID: Type Descriptor:'' Collected From: Bill to: Location’s/lndividual's Name_________________________ Name/Compahy Street_____ __ ___________________________________ Street_________ City/St/Zip__________________________________ _£_____ City/St/Zip Identification of Source ,_____________________ ___ Phone#:_______ Fax#: Collection Point______ _________________________ _ CA,CH, Bl? Check#: Amounts

BACTERIOLOGICAL ANALYSIS Lab#: Lab#: _ ______________________ ORGANIC POTABLE ANALYSIS ' ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count _Z^Yrihalomethanes (524) __ Purgeable Halocarbons (6^4/8260)5 - ' (hemodialysis & all others) jy^jlatile Halocarbons (524) __ Purgeable Aromatics (624/^260) cc __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) _i/wlatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) “< __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides ('608/8081) __ Fecal Coliform (all samples) __ Microextractables (504) __ PCB’s (Arochlors) (608/8081) __ Microscopic __ Pesticides/PCB screen (508) _ Herbicides (SM18/6630,8151) __ Macroscopic- __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SM18/862&)^^ _ API __ Herbicides (515) __ Petroleum Hydrocarbon Scab (>40-13) __ Other;_____________________ _ _ Eesticides^,(525) __ Glycols in Water_________ <7 Refrigerated?yes no __ Carbamate Pesticides (531) __ Acid Extractables (625/8270') no __ Glyphosate (547) __ Base Neutral Extractables (625/8270) Chlorinated:? yes __ Diquat (549) __ GC/MS Unknown Scan Free Chlorine Res: - rng/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 _ MtBE Only (524) __ Radon __ Other __ __________________

INORGANIC ANALYSIS REQUESTED - Lab#: __ 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 __ 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-violatiies __ Total Organic Halides __ Nitrogen,' Total Kjeldahl as N __ Cobalt __ Pesticides/PCB's __ Solids, Percent (%) __ Oil and Grease __ Copper __ Solids, Settleable __ Phenol __ Iron TCLP __ Solids, Suspended __ Phosphorus Total as P __ Lead _TCLP-Metals __ 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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