Chain of Custody Record, Westchester County Lab, Feb 2002

NYC 9/11 Public Portal Document

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■Illi ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM MB stcr ■■ 3A 'OHS a WESTCHESTER COUNTY LABORATORIES ANO RESEARCf! 2 Dana Road, Valhalla, New York 10695 (914) 231-1620 Fax (914) 231-1772 jolEfedil' I Time/Date Set:^ NYS-ELAP No. 10108 FprmA~70 (rev. 10/01)

iilli Sanipic Type ...... 1. Potable 3. Non Potable Treated Bottle #'s:____ _____ _______ -.r \ ./... *

I ill 2. Non Potable

Time/Date Collected:■ ■■ 4. Other

.' ' Chain of Custody?Yes

Comments: No I

J Collected By: £> • /i A - Agency Code: PWS #:_______ Source ID:Type Descriptor:

I Collected From: Location’s/lndividual's Name Z' C 7... Bill to: Name/Company; Street SToef City;St/7ip .......................... CitytSt/Zin ■I identification of Source Phone#:J - Fax#: „ M Collection Point UCA O/--

I CA,CH, Bi?: Check#: .j AmountSj

BACTERIOLOGSCAL ANALYSIS Lab#: iBi Lab#: , Jill ORGANIC POTABi.E ANALYSIS ORGANIC NON POTABLE/SOLID ANAC'SIS

I __ Heterotrophic Plate Count __ Trihatomethanes (524) __ Purgeable Halocarbons (624/8260) (hemodialysis & all others) __ Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) __ Volatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) __ Fecal Coliform (ail samples) __ . Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081) __ Microscopic Microextractables (504) PCB's (Arochlors) (608/8081)

fei „ Macroscopic API _ Pesticides/PCB screen (508) __ PCB as Decachlorobiphenyl (508A) _ Herbicides (515) III: __ Herbicides (SM18/6630.8151) __ Other Pesticides (SM18/6630) __ Petroleum Hydrocarbon Scan (310-13) ___ Other:_______________________ __ Pesticides (525) __ Glycols in Water

■ Refrigerated?yes Chlorinated:? w Free Chlorine Res:mg/L yes no no __ Carbamate Pesticides (531) __ Giyohosate (547) Diquat (549) __ Acid Extractables (625/8270) __ Base Neutral Extractables (625/8270) _XjeC7MS Unknown Scan

K Total Chlorine Res:mg/L __ Chlorination Disinfection Byproducts (551) __ Haloacetic Acids (552) __ Phthalates (606MS) __ Other:____________ _____________ _______

■ pH_____________

RADiOCHEMiCAL ANALYSIS __ Other Pesticides (SMI8/6630) _.UCMRList1 __MtBE Only (524) ___Radon __ Other_________ _ __ ____________ If 111 iNORGANiC ANALYSIS REQUESTED - 1 _ Color __ Acidity __ Potassium __ Turbidity __ Alkalinity ^-Antimony _i-86lenium _ pH __ Bromide __rArsenic _rSHver Conductivity __ Brornate/Chiorate/Chlorite ..J^arium ... tkuhisn; 111 ■ __ Corrosivity (temp _ BOD (5 day) “C) __ Chloride __ Cyanide _7lBeryiliurn __ Boron Ux-Thallium __ V^adium _ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium j»r-i3nc

IIf .... Solublo BOD th day) __ Chemical Oxygen Demand __ Dissolved Oxygen __ Total Organic Carbon _ Hardness. Total as CaCOs __ Nitrogen, Ammonia as N __ Nitrogen, Nitrate as N __ Nitrogen, Nitrite as N ___Calcium, as CaCOa C^ium, Ca’S ..i^Chromium, Total __ Chromium, Hexavalent “clip __ Metals/CN __ Volatiles __ Semi-violatiies __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N ..TrCpbalt I ill __ Solids, Percent (%) __ Solids. Settleable Solids, Suspended __ Oil and Grease __ Phenol ___ Phosphorus Total as P JrCdPper .L/'ron __ Pesticides/PCB's

ICLP ...■.imd _ Solids, Total __ Phosphorus, Ortho as P __TCLP-Metals ■I __ Magnesium ■fCLP-PvssiticKies __ Solids, Total Dissolved _ Sulfates ... Mung; nesi- ■Il ___ S9MS, Total Volatile ___ Surfactants - Mercury _TCLP-Herbicides _::r"t5tter: _____________ , _.-id^oiybdenum iCii’Vohkilcs .. UVZsl __ TCLP-BNAs

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