Chain of Custody Record, Westchester County Lab, Feb 2002

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM jster WESTCHESTER COUNTY LABORATORIES AND RESEARCH .A.cnni ■ illli 2 Dana Road, Valhalla, New York 10595 SB (914)231-1620 Fax (914) 231-1772 NYS-ELAP No. 10108 Time/Date Set: Form AYO (rev. 10/01)

Sample Type (circle one); 1. Potable 3. Non Potable Treated Bottle #’s:

2. Non Potabie 4. Other_________ , Chain of Custody? ____ Yes No Time/Date Collected; Comments; Collected By: i' ' Agency Code: PWS #:: . Source ID; Type Descriptor:.. .

CoiSected From: Bill to:

Location’s/lndividual’s Name Name/Company: Street_____________ ______ Street;

City/St/Zip________________ : City/St/Zip____ : Identification of Source: Phone#;i Fax#:: Collection Point. tYEl CA.CH, Bi? Check#;: Amounts i

BACTERIOLOGICAi. ANALYSIS Lab#;: Lab#:i ORGANIC POTABt.E ANALYSIS ORGANIC NONPOTABI.E/SOLID ANALYSIS __ Heterotrophic Plate Count __ Tuhalomethanes (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) __ Pesticides/PCB screen (508) __ Herbicides (SM18/6630,8151) __ Macroscopic __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SM18/6630) API __ Herbicides (515) Petroleum Hydrocarbon Scan (310-13) __ Other:: __ Pesticides (525) __ Glycols in Water Refrigerated?... .. .. yes no __ Carbamate Pesticides (531) __ Acid Extractables (625/8270) Chlorinated;? yes: no __ Glyphosate (547) „ Bast? Neutral Extractables (625/8270) __ Diquat (549) GC/MS Unknown Scan Free Chlorine Res;: . mg/Li __ Chlorination Disinfection Byproducts (551) ___ Phthalates (606MS) Total Chlorine Res:: mg/L; __ Haioacetic Acids (.552) __ Other:; __ Other Pesticides (SMI8/6630) pH_____________ _ UCMR List 1 RADIOCHEMICAL ANALYSIS „ MtBE Only (524) OBIHWSl __ Radon — Other______________________

INORGANiC ANALYSIS REQUESTED - Lal.v __ Color Acidity __ Aluminum __ Potassium Turbidity __ Alkalinity __ Antimony _ Selenium — pH __ Bromide __ Arsenic __ Silver __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium __ Corrosivity (temp: °C) __ Chloride __ Beryllium __ Thallium _ BOD (5 day) __ Cyanide __ Boron __ Vanadium Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Zinc _ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOs __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium. Ca-’2 __ Metals/CN __ Dissolved Oxygen __ Nitrogen, Nitrate as N __ Chromium, Total __ 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 __ Solids, Settleable __ Phenol __ iron TCLP __ Solids, Suspended __ Phosphorus Total as P __ Lead __„TCLP-Metals Solids, Total _ Phosphorus, Ortho as P __ Magnesium __ TCLP-Pesticides __ Solids, Total Dissolved Sulfates __ Manganese _TCLP-Herbicides __ Solids, Total Volatile _ Surfactants __ Mercury „ TCLP-Volatiles __ Other:: _ UV254 __ Molybdenum 1 _ TCLP-BNA's _ Nickel

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