Chain of Custody Record, Westchester County Lab, Feb 2002

NYC 9/11 Public Portal Document

ACC;,. ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH ■ 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 IB Bi iij- .Id* NYS-ELAP No. 10108 Time/Date Set: Form A-70 (rev. 10/0 i)

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

2. Non Potable 4. Other_____________ i Chain of Custody? Yes No; Time/Date Collected; CetrnimMs; . ..

Collected By:; Agency Code:; PWS #:, Source ID; Type Descriptor; CoSiecteri From; BiU lo'

Location’s/lndividuai’s Name „ IIIBBi Name/Company Street__________________ _ _ ’ Street; ____ Idsritification of Source_____ ; Phone#:_______ _ . Fax#:;

IB Collection Point________ 1___ J III CA.CH, Bi? Check#: Amount$_j

BAGTtRIOLOGiCAl. ANALYSIS Lab#:; Lab#;__________________________ _ ORGANIC POTABLE ANAi.' SiS ORGANIC NONPOTAELE/SOt.iO ANALYSIS __ Heterotrophic Plate Count __ Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) (hemodialysis & ai! others) __ Volatile Halocarbons (524) Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) Coliform MPN (priv well, raw, s!p) __ Volatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) ■I __ Fecal Coliform (ail samples) __ Total Trihalomethane Potential (510) __ Microextractables (504) __ Organochlorine Pesticides (608/8061) _ PCB’s (Arochlors) (608/8081) __ Microscopic _ Macroscopic __ Pesticides/PCB screen (508) ... Herbicides (SM18/6630.8151) ■I _ API __ PCB as Decachlorobiphenyl (508A) .... Other Pesticides (SM18/6630) ......... Other:_____________________ _ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) .....Pesticides (525) __ Glycols in Water Refrigerated?yes no __ Carbamate Pesticides (531) __ Acid Extractables (625/8270) Chlorinated;? yes__ J. 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)

■I Total Chlorine Res:mg/L: Haloacetic Acids (552) Other Pesticides (SMI8/6630) __ Other:_____________ _ ________________

pH _____________ __UCMRList1 RADiOCHEMiCAL ANALYSIS _ MIBE Only (524) __ Radon .... Other;

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Acidity __ Aluminum __ Potassium Turbidity __ Alkalinity __ Antimony __ Selenium pH __ Bromide __ Arsenic __ Silver

o ill __ Conductivity Corrosivity (temp: __ BOD (5 day) “C) __ Bromate/Chlorate/Chlorite __ Chloride __ Cyanide __ Barium __ Beryllium __ Boron __ Sodium __ Thallium __ Vanadium II

I Carbonaceous BOD (5 day) „ Soluble BOD (5 day) __ Chemical Oxygen Demand __ Fluoride __ Hardness, lota! as CaCOs __ Nitrogen, Ammonia as N __ Cadmium __ Calcium, as CaCOs __ Calcium, Ca*2 __ Zinc

_ Metals. CN __ Dissolved Oxygen __ Nitrogen, Nitrate as N __ Chromium, Total ■I Total Organic Carbon __ Nitrogen, Nitrite as N _ Chromium, Hexavalent __ Volatiles __ Semi-vioiatiles

I: ■l Total Organic Halides Solids, Percent (%) ..... Solids, Settleable __ Solids, Suspended __ Nitrogen, Total Kjeldahl as N __ Oil and Grease __ Phenol Phosphorus Total as P .....Cobalt __ Copper __ iron __ Lead __ Pesticides/PCB’s

TCLP _TCLP-Metals __ Solids, Total __ Phosphorus, Ortho as P __ Magnesium ■I __ Solids, Total Dissolved __ Sulfates __ Manganese TCLP-Pesticides _TCLP-Herbicides

I ilill __ Solids, Total Volatile _ Other:___________________ ; __ Surfactants _ UV254 __ Mercury Molybdenum _ Nickel __ TCLP-Volatiles „ TCLP-BNAs

NYC-WTC_000074273