Chain of Custody Record, Westchester County Lab, Feb 2002

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ..AVestehestei' WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914) 231-1620 Fax (914) 231-1772 NYS-ELXp No. 10108 Time/Date Set: Form AYO (rev. 10/01) 1 Sample Type (circle one): r 1. Potable 3. Non Potable Treated Bottle #’s: 2. Non Potable 4. Other____________ Chain of Custody? Yes No Time/Date Collected: Comments:

V Collected By: . Agency Code: <.< PWS #: Source ID: Type Descriptor: Collected From: Bill to:

I Location’s/lndividual’s Name Street_________ ________ Name/Company Street City/St/Zip City/St/Zip______________ I Identification of Source Phone#: Fax#: Collection Point CA,CH, Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS Lab#: Lab#: __ ____________________ f ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count __ Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) & (hemodialysis & all others) __ Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) __ Coliform MPN (privwell, raw, stp) __ Volatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081) __ Fecal Coliform (all samples) __ 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 __ Other:_____________________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) __ Pesticides (525) __ Glycols in Water Refrigerated?yes no __ Carbamate Pesticides (531) _ Acid Extractables (625/8270) no __ Glyphosate (547) __ Base Neutral Extractables (625/8270) Chlorinated:? yes __ Diquat (549) _V 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 ------------------- __ UCMRListI I

I; RADIOCHEMICAL ANALYSIS Radon __ Other __ _________________ _ MtBE Only (524) I

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Acidity __ Aluminum __ Potassium' __ Turbidity __ Alkalinity __ Antimony __ Selenium _ pH __ Bromide __ Arsenic __ Silver s .. __ Bromate/Chlorate/Chlorite __ Barium __ Conductivity __ Sodium , __ Corrosivity (temp:. .°C) __ Chloride __ Beryllium __ Thallium _ BOD (5 day) __ Cyanide __ Boron __ Vanadium' __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Zinc I _ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOa CLP __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca+2 _ Metals/CN Dissolved Oxygen __ Nitrogen,'Nitrate as N __ Chromium, Total . k __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Nitrogen, Total Kjeldahl as N __ Chromium, Hexavalent __ Cobalt __ Volatiles __ Semi-violatiles __ Total Organic Halides r __ Solids, Percent (%) __ Solids, Settleable __ Oil and Grease __ Phenol __ Copper __ Iron __ Pesticides/PCB’s

ICLP __ Lead k- __ Solids, Suspended __ Solids, Total __ Phosphorus Total as P __ Phosphorus, Ortho as P __ Magnesium _TCLP-Metals __ TCL P-Pesticides __ Solids, Total Dissolved __ Sulfates __ Manganese I __ Solids, Total Volatile __ ' Other:_________________ __ Surfactants _ UV254 __ Mercury _ Molybdenum __ TCL P-Herbicides __ TCLP-Volatiles _ TCL P-BNA's __ Nickel I

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