Chain of Custody Record, Westchester County Lab, Feb 2002

NYC 9/11 Public Portal Document

ACCn ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 ! S NYS-ELAP No. 10108 * Time/Date Set: Form A-70 (rev. 10/01) kif — Sampje.Type (circle one): K'Potable. 3. Non Potable Treated Bottle #’s:

2. Non Potable 4. Other Chain of Custody? Yes___ No time/Date Collected: Comments: Collected By: Agency Code: PWS #:_________ Source ID: Type Descriptor: Collected From: Bill to: Location’s/lndividual’s Name Name/Company Street____________________ ‘street__________

City/St/Zip________________ 1 City/St/Zip Identification of Source r Phone#:________ Fax#: Collection Point' I / ' '4 .J CA,CH, Bl? Check#: Amounts. t I I BACTERIOLOGICAL ANALYSIS Lab#: Lab#:__________________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS _ Heterotrophic Plate Count __ Trihalornethanes (524) __ Purgeable Halocarbons ,(624/8260) (hemodialysis & all others) __ Volatile Halocarbons (524) _ Purgeable Aromatics (624/8260) •s ,__ Coliform P/A (Public supplies) ___ Coliform MPN (priv well, raw, stp) __ Volatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) i 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) _ API __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SMI8/6630)

s __ Other:_______________________

Refrigerated?yes___ no __ Herbicides (515) __ Pesticides (525) __ Carbamate Pesticides (531) __ Glyphosate (547) __ Petroleum Hydrocarbon'Scan (310-13) __ Glycols in Water __ Acid Extractables (625/8270) t

__ Base Neutral Extractables (625/8270) Chlorinated:? yes no __ Diquat (549) -GC/MS Unknown Scan 0^ Free Chlorine Res:mg/L Total Chlorine Res:mg/L __ Chlorination Disinfection Byproducts (551) . Haloacetic Acids (552) _ Phthalates (606MS) __ Other:_______________ •_Other Pesticides (SM18/6630) pH _________ ___ _UCMRList1 RADIOCHEMICAL ANALYSIS __ MtBE Only (524) __ IRadon

'F __ Other_______________________

INORGANIC ANALYSIS REQUESTED - Lab#: • z SM I I __ Color I’ IK­ __ Acidity __ Aluminum __ Potassium __ Turbidity __ Alkalinity __ Antimony. __ Selenium 'S- _ pH __ Conductivity __ Bromide __ Bromate/Chlorate/Chlorite __ Arsenic __ Silver I . __ Barium __ Sodium )__ Corrosivity (temp:. °C) __ Chloride Beryllium __ Thallium _ BOD (5 day) __ Cyanide __ Boron __ Vanadium’ __ Carbonaceous BOD (5 day) __ Fluoride r __ Cadmium _ Soluble BOD (5 day) __ Hardness, Total as CaCO's __ Calcium, as CaCOa JL’Zinc , ' 4 CLP “ __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca+2 •’ I _ Metals/CN f

I __ Dissolved Oxygen __ Nitrogen, Nitrate as N _Chromium, Total __ Volatiles I __ 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 I

s !_ Solids, Settleable __ Solids, Suspended __ Solids, Total __ Phenol __ Phosphorus Total as P __ Phosphorus, Ortho as P __ Iron __ Lead __ Magnesium ICLP _TCLP-Metals _TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates __ Manganese _TCLP-Herbicides __ Solids, Total Volatile __ Surfactants __ Mercury _ TCLP-Volatiles' .^'Other: _ UV254 __ Molybdenum _ TCLP-BNAs __ Nickel

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