Chain of Custody Record, Westchester County Lab, Feb 2002

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM 'Westchester WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana* Road, Valhalla, New York 10595 c zn A o/ ■ I (914)231-1620 Fax (914) 231-1772 iS „^NYS-ELAP No. 10108 Time/Date Set: 'Form A-70 (rev.10/01)

Sample Type (circle one): : i. Potable 3. Non Potable Treated Bottle #’s: ' ■'

2. Non Potable 4. Other_____________ Chain of Custody? Yes No f i ' Time/Date Collected: ' \ / *1 Comments: Collected By: 'A . i3 Agency Code: PWS #:_________ Source ID: Type Descriptor: I Collected From: Bill to: .Location’s/lndividual’s Name Name/Company Street _________________ Street J- City/St/Zip________________ Citv/St/Zio i Identification of Source Phone#: Fax#: Collection Point___________ ; CA.CH, Bl? Check#: Amounts h' BACTERIOLOGICAL ANALYSIS Lab#: i Lab#:__________________________ I ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ : Heterotrophic Plate Count f (hemodialysis & all others) __ Trihalomethanes (524) __ Volatile Halocarbons (524) __ Purgeable Halocarbons (624/8260) __ Purgeable Aromatics (624/8260) ___ Coliform P/A (Public supplies) ;__ Coliform MPN (priv well, raw, stp) __ Volatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) __ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) _ Organochlorine Pesticides (608/8081) __ 'Microscopic __ Microextractables (504) __ PCB’s (Arochlors) (608/8081) __ j Macroscopic __ Pesticides/PCB screen (508) _ Herbicides (SMI 8/6630,8151) __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SMI8/6630) _ API __ Other:=L __ 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 • t- 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 i ’__ Other_______________________

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INORGANIC ANALYSIS REQUESTED - Lab#: ■■ I, __

__ Color __ .-/'cidity __ 'Aluminum __ Potassium __ Turbidity __ Alkalinity _y Antimony ^-Selenium I _ pH __ Conductivity __ Bromide __ Bromate/Chlorate/Chlorite ' 'Arsenic Barium -■Silver __ Sodium (

__ Corrosivity (temp: °C) __ Chloride ^Beryllium _i.'Thallium f _ BOD (5 day) __ Cyanide __ _Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium I /Zinc _ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOs ciZp A __ 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 __ Sem i-vio'latiles __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N __ Cobalt __ Pesticides/PCB’s __ Solids, Percent (%) , __ Oil and Grease __ Copper __ Solids, Settleable __ Phenol __ Iron ICLP I I __ 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 _ TCL P-Volatiles t: Other:___________________ _ UV254 Molybdenum _ TCLP-BNA’s __ Nickel S;

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