Chain of custody record, Sample AE04125, Feb 2002

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM *stcr WESTCHESTER COUNTY LABORATORIES AND RESEARCH

III )V.conr 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 nelc -'"NYS-ELAP No. 10108 Time/Date Set: ..form A-70 (rev. 10/01)

-Sampl® Type (circle one): 1. Potable. 3. Non Potable Treated Bottle ;

2. Non Potable 4. Other Chain of Custody? Yes No Time/Date Collected: ■ Comments Collected By:_____________ Agency Code; PWS #:__________ Source ID? Type Descriptor: CoHcclod ( rnui: Locatlon's/'individual’s Name ■ 1 Eiiil to: Name/Company Street____________________; Street; City/St/Zip________________: City/St/Zip Identification of Source____ ; Phone#:; Fax#: Collection Point I CA.CH, Bl? Check#: Amounts,

■I BACTERIOLOGICAL ANALYSIS Lab#::

■ Lab#:__________________________ __ Heterotrophic Plate Count ORGANIC POTABLE ANALYSIS __ Trihalomethanes (524) ORGANIC NONPOTABLE/SOLID ANALYSIS __ Purgeable Halocarbons (624./8260) (hemodialysis & ail others) __ Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, sip) __ Volatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081) __ Fecal Coliform (ail samples) __ Microscopic __ Microextractables (504) _ PCB’s (Arochlors) (608/8081)

■I Macroscobic API _ Pesticides/PCB screen (508) __ PCB as Decachlorobiphenyl (508A) _ Herbicides (SM18/6630,8151) __ Other Pesticides (SM18/6630) ■II __ Other:_______________________ _ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) __ Pesticides (525) __ Glycols in Water Bl !pHI Refrigerated?yes no; __ Carbamate Pesticides (531) __ Acid Extractables (625/8270)

■ ■I Chlorinated:? Free Chlorine Res:, yes no mq/L __ Glyphosate (547) _ Diquat (549) __ Chlorination Disinfection Byproducts (551) __ ^se Neutral Extractables (625/8270) GC/MS Unknown Scan Phthalates (606MS) Total Chlorine Res: .... .. .. mg/L __ Haloacetic Acids (552) __ Other:________________________________ __ Other Pesticides (SM18/6630,) I pH _____________ _UCMRList1

■ RADIOCHEMICAL ANALYSIS __ Radon ___ MtBE Only (524)

■ _ Other i

iNORGANiC ANALYSIS REQUESTED - l .m/; __ Color __ .Acidity __ Aluminum __ Potassium * __Turbidity __ Alkalinity __ Antimony _ Selenium pH __ Bromide _ Arsenic _ Silver __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium _ Corrosivity (temp: _ ?’C) __ Chloride __ Thallium Uli! _ BOD (5 day) __ Cyanide __ Boron __ Vanadium __ Carbonaceous BOD (5 day) Fluoride __ Cadmium _ Zinc

I __ Soluble BOD (5 day) __ Chemical Oxygen Demand __ Dissolved Oxygen __ Hardness, Total as CaCOs Nitrogen, Ammonia as N __ Nitrogen, Nitrate as N __ Calcium, as CaCO3 __ Calcium, Ca*2 __ Chromium. Total __ Metals/CN ,

i _ Total Organic Carbon Total Organic Halides __ Nitrogen. Nitrite as N __ Nitrogen, Total Kjeldahl as N __ Chromium, Hexavalent _jjCobalt __ Volatiles __ Semi-viol allies __ Pesticides/PCB's Solids. Percent (%) __ Oil and Grease __ Copper __ Solids, Settieabie __ Phenol __ Iron ■I Solids, Suspended __ Solids, Total __ Phosphorus Total as P __ Phosphorus, Ortho as P __ Lead __ Magnesium tclp __TCLP-Metals _ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates __ Manganese _TCLP-Herbicides __ ..Solids, Total Volatile Surfactants __ Mercury TCLP-Volatiles other:___________________ _ UV254 __ Molybdenum __ TCLPBNA-s __ Nickel

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