Chain of Custody Record, Westchester County Lab, Feb 2002

NYC 9/11 Public Portal Document

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

NYS-ELAP No. 10108 Time/Date Set: Form A-70 (rev,10/01) ■ Sample Type (circle one):

I 1. Potable 2. Non Potable 3. Non Potable Treated 4. Other: Bottle #'s: Chain of Custody?; Yes No

I: ■■I Time/Date Collected: Agency Code:: Comments- PWS #:: . . Source ID; .Type Descriptor: Collected By:_______________ Collected From: Biii to 11 Location’s/lndividual’s Name Name/Company

II ■ Street______________________ j C.tv/St/Z:p Street__________ _ City/St/Zip

Identification of Source______ : Phone#:: Fax#::

■ Collection Point______ ____ __ j CA.CH, Bi? Check#; Amounts

BACFERiOLOGICAL ANAL YSIS Lab#:^ Lab#:___________________________ : ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLF/SOLID ANALYSIS

I __ Heterotrophic Plate Count (hemodialysis & all others) __ Coliform P/A (Public supplies) Trihalomethanes (524) Volatile Halocarbons (524) __ Purgeable Halocarbons (624/8260) __ Purgeable Aromatics (624/8260) __ Coliform MPN (priv well, raw, stp) __ Volatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) __ Fecal Coliform (ail samples) Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081) __ Microextractables (504) PCB's (Arochlors) (608/8081) __ Microscopic __ Pesticides/PCB screen (508) „ Herbicides (SM18/6630,8151) __ Macroscopic _ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SMI8/6630) __ API __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) __ Other:______ _______________ _ _ j Bl Illi __ Pesticides (525) __ Glycols in Water 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 Bl Free Chlorine Res: mq/L __ Chlorination Disinfection Byproducts (551) Phthalates (606MS) Total Chlorine Res:: _ mg/L __ Haloacetic Acids (552) __ other:: „„ Other Pesticides (SM18/6630): pH_______ ___ I: r; radiochemical analysis ___ Radon ._..UCMRList 1 _ MtBE Only (524)

IM __ Other________________________ _

B' _ ■ ' _______________________________

:p|l iNORGANiC ANALYSIS REQUESTED - i ab#: fill __ Color Acidity: __ Aluminum __ Potassium

i __ Turbidity — pH __ Conductivity __ Alkalinity __ Bromide __ Bromate/Chlorate/Chlorite __ Antimony __ Arsenic __ Barium __Selenium _ Silver Sodium __ Corrosivity (temp:_ ,“C): __ Chloride __ Beryllium

I Thallium __ BOD (5 day) __ Cyanide __ Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Zinc til Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCO:j & __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca '2 „ Metals/CN Dissolved Oxvgon __ Nitrogen, Nitrate as N __Chromium, Total ■ili __ Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium. Hexavalent __ Semi-violatiles Total Organic Halides __ Nitrogen, Total Kjeldahl as N Cobalt __ Pesticides/PCB's __ Solids, Percent (%) __ Oil and Grease __ Copper <^111 Solids, Settleable __ Phenol _ iron rcLP t:: __ Solids, Suspended __ Solids, Total __ Phosphorus Total as P Phosphorus, Ortho as P __ Lead __ Magnesium _TCLP-Metals I' __ Solids, Total Dissolved Sulfates __ Manganese _TCLP-Pesticides _TCLP-Herbicides __ Solids, Total Volatile Surfactants __ Mercury . TCLP-Volatiles __ Other;: _ UV254 __ Molybdenum KV-nNAs _ Nickel

NYC-WTC_000074244