Chain of Custody Record, Westchester County Lab, Feb 2002

NYC 9/11 Public Portal Document

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ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 NYS-ELAP No. 10108 - Time/Date Set; Form A-70 (rev.10/01)

Sample Type (circle one): J*' f 1 .Potable , 3. Non Potable Treated Bottle #’s; "^2^ Non Potable 4. Other Chain of Custody? Yes No I jr- ■ .( / r Comments: Time/Date Collected: Collected By: 3 /f:"-' Agency Code; PWS #:________ Source ID: Type Descriptor: t Collected From: Bill to: Location’s/lndividual’s Name Name/Company Street_________________ Street_________ City/St/Zip______ _______ City/St/Zip Identification of Source Phone#:_______ Fax#: Collection Point CA,CH, Bl? Check#: Amounts,

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:_________ ______________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS _ Heterotrophic Plate Count __ Trihalomethanes (524) _ Purgeable Halocarbons (624/8260) A (hemodialysis & all others) s- __ Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) _ 1 Coliform P/A (Public supplies) _ Coliform MPN (priv well, raw, stp) __ Volatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081) I __ Fecal Coliform (all samples) _ Microscopic __ Microextractables (504) _ PCB’s (Arochlors) (608/8081) __ -Macroscopic __ Pesticides/PCB screen (508) _ Herbicides (SMI8/6630,8151) __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SMI8/6630) _ API __ Other;___________________ _ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) ■ t ■__ Pesticides (525) __ Glycols in Water Refrigerated?yes__ ^no __ Carbamate Pesticides (531) __ Acid Extractables (625/8270) __ Glyphosate (547) __ Base Neutral Extractables j (625/8270) Chlorinated:? yes no __ Diquat (549) lYGC/MS Unknown Scan

r Free Chlorine Res:mg/L Total Chlorine Res:mg/L pH _________ __ Chlorination Disinfection Byproducts (551) __ Haloacetic Acids (552) __ Other Pesticides (SM18/6630) _UCMRList1 _ Phthalates (606MS) __ Other:___________

RADIOCHEMICAL ANALYSIS _MtBEOnly (524) __ Radon __ Other.

*. 1 '■ i INORGANIC ANALYSIS REQUESTED - Lab#; __ Color __ /V;idity lir'Aluminum __ Potassium __ Turbidity __ Alkalinity -Antimony ^Selenium — pH __ Bromide _ >Arsenic _>--Silver f _ _ Conductivity __ Bromate/Chlorate/Chlorite _i:r'Barium __ Sodium

i; __ Corrosivity (temp: BOD (5 day) ’__ Carbonaceous BOD (5 day) °C) __ Chloride __ Cyanide __ Fluoride _i_rBeryllium __ Boron __ Cadmium _::r-Thallium __ Vanadium /-^Zihc

f _ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOs __ Chemical Oxygen Demand __ Nitrogen, Arhmonia as N __ Calcium, Ca*^ clF ' _ Metals/CN __ Dissolved Oxygen __ Nitrogen, Nitrate as N _Chromium, Total __ Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Seml-violatiles L" __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N Cobalt __ Pesticides/PCB’s St.' __ Solids, Percent (%) __ Oil and Grease z-CoDper __ Solids, Settleable __ Phenol -^Iron I TCLP __ Solids, Suspended __ Phosphorus Total as P _i_-Lead _TCLP-Metals ' n. __ Solids, Total __ Phosphorus, Ortho as P __ Magnesium __ TCLP-Pesticides '__ Solids, Total Dissolved __ Sulfates i -Manganese __ TCLP-Herbicides __ Solids, Total Volatile __ Surfactants _i:rMercury _ TCLP-Volatiles Other: ___________ _ UV254 Molybdenum _ TCLP-BNAs _ir'‘Nickel _____________ t NYC-WTC_(i00074364