Chain of Custody Record, Westchester County Lab, Feb 2002

NYC 9/11 Public Portal Document

g/ fe­ ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AiND RESEARCH llI ; «a lM 2 Dana Road, Valhalla, New York 1059:)5 (914)231-1620 Fax (914) 231-1772 Si

O 1" SB NVS-EIAf'Nc 10MS

P Time/Date Set; _y /Form A-70 (rev. 10/01)

■ Sample Type (circle one): ; 1. Potable 3, Non Potable Treated Bottle #'s: laoa— I 2, Non Potable 4, Other: Chain of Custody? Yes No

I ■ ■pinoTJ-?;.- Cnli -HoT . Collected By; g .......... V.^'/gg/' iZ _____ Agency Code: Comments; PWS #:_______ Source ID; Type Descriptor;:

o Colioctod From: Bill 1o:

1 Location's/lndividual's Name Name/Company

H ■ City/SVZip: Cily'Si'Zb . Identification of Source: Phone#;______ : Fax#:^ ■I 'Collection Point: .A CA,CH, Bl? Check#;Amounts,

BACTERIOLOGICAL ANAi YSiS Lab#: Lab#;_______________ ___________

I ■■ __ Heterotrophic Plate Count (hemodialysis & all others) ORGANIC POTABLE ANALYSIS __ Trihalomethanes (524) __ Volatile Halocarbons (524) ORGANIC NONPOTABLE/SOLID ANALYSIS __ Purgeable Halocarbons (624/8260) __ Purgeabie Aromatics (624/8260)

I __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) __ Fecal Coliform (ail samples) __ Microscopic __ Volatile Aromatics (524) __ Total Trihaiomethane Potential (510) __ Microextractables (504) Acrolein & Acrylonitrile (8260) __ Organochlorine Pesticides (608/8081) _ RGB's (Arochlors) (608/8081) __ Pesticides/PCB screen (5Q8)

I ___ Macroscopic _ Herbiqides (SMI8/6630,8151) __ PCB as Decachiorobiphenyi (508A) __ Other Pesticides (SMI8/6630) __ API __ Other:: __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13)

I Refrigerated?yes no __ Pesticides (525) __ Carbamate Pesticides (531) __ Glyphosate (547) __ Glycols in Water Acid Extractabies (625/8270) _ Base Neutral Extractabies (625/8270)

I Chlorinated:?yes no __ Diquat (549) GC/MS Unknown Scan Free Chlorine Res:mg/L ___ Chlorination Disinfection Byproducts (551) „ Phthalates (606MSf Ol Tdtal Chlorine Res: mg/L __ Haloacetic Acids (552) . „ Other Pesticides (SMI8/6630) __ Other:_____ ______________ _____

„UCMRList1

I ■Il RADiOCHEMiCAi. ANALYSIS __Radon __ Other __ _________ ___________ _ __ MtBE Only (524) Si

■ INORGANIC ANALYSIS REQUESTED ■ Lab#: _ _ Color __ Acidity: __ Aluminum :WII __ Turbidity Alkalinity __ Antimony

I pH Conductivity __ Corrosivity (temp:: “C): __ Bromide ___ Bromate/Chlorate/Chlorite __ Chloride __ Arsenic __ Barium Beryllium iIBb’ IBl ’111 BOD (5 day) __ Carbonaceous BOD (5 day) Soluble BOD (5 day) __ Chemical Oxygen Demand __ Cyanide __ Fluoride _ Hardness, Total as CaCOs ..BBofdh ‘ ' ___ Cadmium _ Calcium, as CaCOa .,._;"Vanaclium

CLP __ Nitrogen, Ammonia as N __ Calcium, ■II __ Dissolved Oxygen __ Nitrogen, Nitrate as N ___ Chromium, Total , __ Metais/CN __ Total Organic Carbon __ Volatiles Nitrogen, Nitrite as N __ Chromium, Hexavaienf

■ __ Total Organic Halides __ Solids, Percent (%) Nitrogen, Total Kjeldahl as N niland Grease __ Oil _ Cobalt \ __ Copper _ Semi-violafiles _ Pesticides/PCB's

I __ Solids, Settleable __ Solids, Suspended ___ Phenol __ Phosphorus Total as P '__ Iron Lead.. •••' rcLP „TCLP-Metais ■I __ Solids, Total _ Phosphorus, Ortho as P Magnesium .. TCLP-Pesticides _ Solids, Total Dissolved „ Sulfates :__ Manganese \ __ TCLP-Herbicides _ Solids, Total Volatile __ Surfactants ■__ Mercury TCLP-Volatiles - / Other: I' /,/j _ UV254 __ MolytxJenum __ TCLP-BNAs • __ Nickel

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