Chain of Custody Record, Westchester County Lab, Feb 2002

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM . ■/ i... 1 I WESTCHESTER COUNTY LABORATORIES AND RESEARCH , ; j . 2 Dana Road, Valhalla, New York 10595 q ZlwAal^ I HIM (914)231-1620 Fax (914) 231-1772 NYS-ELAP No. 10108: Time/Date Set; Form A-70 (rev. 10/01)

Sample Type (circle one)? II Bottle #-s: _____ .. . . .......___ ; Y‘ / / , < A ? > T^otable 3. Non Potable Treated Chain of Custody?: Yes No ■I 2. Non Potable 4. Other_____________ : Cnnsr.icnts. Time/Date Collected; _____ _ ___________ i Collected By:__ , Agency Code:: PWS #:_________ : Source ID: .Type Descriptor: Coilecied FiOPi; Bill to: Location’s/lndividual's Name ■J5V 3 X Name/Conipany Street; Street, City/St/Zip J City/St/Zip J identification of Source____ : Phone#:. Fax#; „ Collection Point CA.CH, Bl?i Check#: Amounts

BACrERIOLOGICAt ANALYSIS Lab#: Lab#:: ORGANIC potable; analysis ORGANIC NONPOTASLEZSOLID ANALYSIS __ Heterotrophic Plate Count __ Trihalomethanes (524) __ Purgeabie Halocarbons (624/8260) (heniodiaiysis & all others) __ Coliform P/A (Public supplies) __ Coliform MPN (priv well raw, stp) __ Volatile Halocarbons (524) Volatile Aromatics (524) __ Purgeable Aromatics (624/8260): __ Acrolein & Acrylonitrife (8260) ■ __ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510): Organochlorine Pesticides (608/8081) __ Microscopic __ Microextractables (504) __ PCB’s (Arochlors) (608/8081) __ Macroscopic __ Pesticides/PCB screen (508) Herbicides (SM18/6630.8151) __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SM18/6630) ^■1 __ API __ Herbicides (515) __ Petroteurn Hydrocarbon Scan (310-13) _ Other: , __ Pesticides (525) Glycols in Water Refrigerated?yes nO: __ Carbamate Pesticides (531) Acid Extractables (625/8270) 11 Chlorinated;? yes no __ Glyphosate (547) _ Base Neutral Extractables (625/8270) __Diquat (549) _ GC/MS Unknown Scan Free Chlorine Res: - mg/L __ Chlorination Disinfection Byproducts (551) _ Phthalates (606MS) Total Chlorine Res: - mg/L __ Haloacetic Acids (552) _ Other:_______________________________ __ other Pesticides (SMI8/6630); pH _____________ __ UCMR List 1 RADIOCHEMICAL ANALYSIS _ MtBE Only (524) ___Radon _ Other______________________ _

fNORGANIC ANALYSIS REQUESTED - « __ Color Acidity __ Aluminum __ Potassium „ Turbidity __ Alkalinity __ Antimony __ Selenium pH __ Bromide __ Arsenic . Silver __ Conductivity- __ Bromate/Chiorate/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 CaCO:) __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca« __ Dissolved Oxygen _ Metals/CN __ 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 __ Soiids, Settleable Pheno! _ Iron TCJ.P __ Solids, Suspended __ Phosphorus Total as P __ Lead __TCLP-Metals II __ Soiids, Total __ Phosphorus. Ortho as P __ Magnesium 111 __ TCLP-Pesticides __ Solids, Total Dissolved Sulfates __ Manganese _ TCLP-Herbicides __ Soiids, Total Volatile __ Surfactants ___ Mercury __ TCLP-Volaliles __Other:t;:.« _ UV254 __ MolytxJenum _ TCLP-BNA's _ Nickel

NYC-WTC_000074271