Chain of Custody Record, Westchester County Lab, Feb 2002

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM tester ■ fiA.ei HIV WESTCHESTER COUNTY LABORATOnirS ."ND RFSrARCH (8» 2 Dana Road, Valhalla, New York 10595 Qi 'A * ■I. (914)231-1620 Fax (914) 231-1772 MYS-ELAP No. 10108 Time/Date Set:- Form A-70 (rev. 10/01)

Sample Type (circle one): fl ■■ l. l^otable 3. Non Potable Treated Bottle #’s?

2. Non Potable 4. Other Chain of Custody?: Yes___ No ■I Time/Date Collected: Coninicnts: Collected By: Agency Coder PWS #:________ _ Source ID: Type Descriptor? CoHected From: BUi to Location's/lndividual's Name Name/Company Street_____________________ _ Street__________ _ City/St/Zip___________________ City/Sl/Zip: Identification of Source Phone#:J Fax#: Collection Point_______ ______ ; 11 CA,CH, Bl?... . Check#: Amounts

FiAClERIOLOGICAL ANAi.YSiS Lab#: _ Lab#:; ORGANIC POTABL E ANALYSIS ORGANIC NONPOsAELC/SOLiO ANA; YSiS __ Heterotrophic Plate Count __ Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) (hemodialysis & al! others) __ Volatile Halocarbons (524) Purgeabie Aromatics (624/8260) __ Coliform P/A (Public .supplies) __ Coliform MPN (privwell, raw, sip) __ 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) __ Macroscopic __ Pesticides/PCB screen (508) Herbicides (SMI8/6630,8151) __ PCB as Decachlorobiphenyi (SOSA) __ Other Pesticides (SMI8/6630) ..... API __ 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 no __ Glyphosate (547) Base Neutral Extractables (625/8270) __ Diquat (549) GC/MS Unknown Scan Free Chlorine Res: mg/L __ Chlorination Disinfection Byproducts (551) ___Phthaiates (606MS) Total Chlorine Res: mg/L __ Haloacetic Acids (552) Other; Other Pesticides (SMI8,16630) SB pH _____________ „ UCMRListI MtBE Only (524) lilUHli I RADIOCHEMICAI. ANALYSIS: __ Radon Other; ■

®i INORGANIC ANALYSIS REQUESTED - ! .iKc; ■■ 8H 7J ? LA,/ Color Acidity Aluminum __ Potassium __ Turbidity __ Alkalinity „__ Antimony Selenium pH __ Bromide __ Arsenic Silver Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium __ Corrosivity (temp:, .“C) __ Chloride __ Beryllium _ Thallium JI _ 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*2 __ 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 __ Solids, Percent (%) __ Pesticides/PCB's __ Oil and Grease Copper __ Solids, Settleable __ Pheno! Iron tclp __ Solids, Suspended __ Phosphorus Total as P __ Lead __ Solids. Total _TCLP-Metals Phosphorus, Ortho as P __ Magnesium __ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates __ Manganese __ Solids, Total Volatile __ TCLP-Herbicides Surfactants __ Mercury Other:,; __ TCLP-Volatiles _ UV254 __ Molybdenum TCLPBNAs __ Nickel

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