Chain of custody record, Sample AE04125, 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 ■ sr NY,S'-ELAP No. 10108 Time/Date Set: (^rmA-70 (rev. 10/01)

Sarnpfc Type 1. Potable 3. Non Potable Treated Bottle ff's:

"2) Non Potable 4. Other_____ x._„_4____4.________ Chain of Custody?___ Yes No

Time/Date Collected:.. Conniients. Collected By: „ U v^-u iAgency Code:______ । PWS #:: Source ID: Type Descriptor:

Collected Fl on! Bill to:

■ Bill Location's/lndividual's Name__ : Street_____________________ _ Name/Companyi Street J City/St/Zip■ w City/St/Zip__________________ identification of Source______ : Phone#:: Fax#:

III Collection Point j CA.CH, Bl? ..Check#:.. Amounts:

BACTERIOLOGICAl. ANALYSIS Lab#: H Lab#:___________________________ ORGANIC POIABLE ANALYSIS ORGANIC NONf’O ! ABLE/ SOLID ANAt.YS S pi __ Heterotrophic Plate Count illll (hemodialysis & all ethers) __ Trihaiomethanes (524) __ Purgeable Halocarbons (624/8260) __ Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/.A (Public supplies) __ Volatile Aromatics (524) Acrolein & Acrylonitrile (8260) __ Coliform MPN (priv well, raw. stp) __ Total Trihalornethane Potential (510) __ Organochlorine Pesticides (608/8081) __ Fecal Coliform fail samples) __ Microextractables (504) _ PCB's (Arochlors) (608/8081) __ Microscopic lit __ Macroscopic __ Pesticides/PCB screen (508) __ PCB as Decachlorobiphenyl (508A) Herbicides (SM18/6630,8151) Other Pesticides (SM18/6630)

I? . API __ Other:: I __ Herbicides (515) __ Pesticides (525) Petroleum Hydrocarbon Scan (310-13) Glycols in Water is Refrigerated?: -----yes: no __ Carbamate Pesticides (531) __ Glyphosate (547) __ Acid Extractables (625/8270) __ Base Neutral Extractables (625/8270) ___ yes no Diquat (549) _V0TS/MS Unknown Scan Chlorine Res:: .. mg/L __ Chlorination Disinfection Byproducts (551) ..... Phthalates (606MS) ; Chlorine Res: - mg/L __ Haloacelic Acids (552) __ Other-_____________ _____________ _____ _Other Pesticides (SMI8/6630) I ___ UCMR List 1 ■ ?ADiOCHEMiCM?'ANALY^s' __ MtBE Only (524) ■ tadon - ------------------------------ -

■ Color Turbidity <NtC ANALYSIS REQUESTED -1 nb#: Acidity __ Alkalinity •' ' 11. Aluminum ILfAntirnony __ Potassium 2t^'Selenium pH __ Bromide Arsenic jrl'Silver Conductivity __ Bromate/Chlorate/Chlorite „,_8arium __ Sodium Cyri»-..iviV.- dm.,* ___ “C) __ Chloride Beryllium ..iC Thallium day) __ Cyanide __ Boron __ Vanadium ” L't!’ I 't . L iceous BOD (5 day) __ Fluoride '__ Cadmium ; BOD (5 day): __ Hardness, Total as CaCOs __ Calcium, as CaCOji __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Cjjlcium, Ca'"^ __ Dissolved Oxygen __ Metais/CN __ Nitrogen, Nitrate as N _i-<5hromium. Total __ Volatiles — Total Organic Carbon __ Nitrogen, Nitrite as N ___ Chromium. Hexavalent _ Semi-vioiatiies — Total Organic Halides __ Nitrogen, Total Kjeldahl as N Cobalt Pesticides/PCB’s Solids, Percent (%) __ Oil and Grease Copper ill Solids. Settieabie __ Phenol .i/'lron Solids, Suspended TCLP __ Phosphorus Total as P Lead Coigns, Total . __TCLP-Metals __ Phosphorus, Ortho as P ___ Magnesium ids, Total Dissolvedi _ TCLP-Pesticides __ Sulfates Manganese i ds. Total Volatile _ Surfactants ^Mercury __ TCLP-Herbicides _ TCLP-Volatiles F 3r:_______ \ Y —*r-i ... UV254 „Molybdenum __ Nickel __ TCLP-BNA’s

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