Chain of Custody Record, Westchester County Lab, Feb 2002

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 fi NYS-ELAP No. 10108 Fa-

I. Time/Date Set: Form A-70 (rev. 10/01) i t Sample Type (circle one) 1. Potable 3. Non Potable Treated Bottle #’s:______________ L ! 2. Non Potable 4. Other_____________ Chain of Custody?___ Yes 2 No Time/Date Collected: Comments: te Collected By:; ,,*• I Agency Code: PWS #:_____ _ Source ID: Type Descriptor: I Collected From:- Bill to:

Location's/lndividual’s Name Name/Company

Street____________________ Street _____

City/St/Zip________________ City/St/Zip

Identification of Source Phone#: Fax#: I Collection Point CA,CH, Bl? Check#: Amounts.

I- BACTERIOLOGICAL ANALYSIS Lab#: Lab#:___________________________ < J ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count __ Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) < (hemodialysis & all others) , b _ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) __ Volatile Halocarbons (524) __ Volatile Aromatics (524) __ Purgeable Aromatics (624/8260) __ Acrolein & Acrylonitrile (8260) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081) '5. __ Fecal Coliform (all samples) __ Microextractables (504) _ PCB's (Arochlors) (608/8081)' __ Microscopic __ Pesticides/PCB screen (508) _ Herbicides (SM18/6630,8151); __ Macroscopic __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SMI8/6630) _ API __ Other:________________________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan ^(310-13) __ Pesticides (525) __ Glycols in Water t Refrigerated?yes no’ __ Carbamate Pesticides (531) _ Acid Extractables (625/8270) I. Chlorinated:? yes___ no __ Glyphosate (547) __ Base Neutral Extractables (625/8270) __ Diquat (549) _Y’ 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 _____________ _UCMR List 1

I RADIOCHEMICAL ANALYSIS ___ Radon __ Other_______________________ _ MtBE Only (524)

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Acidity __ Aluminum __ Potassium __ Turbidity __ Alkalinity __ Antimony __ Selenium _ pH __ Bromide __ Arsenic __ Silver __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium __ Corrosivity (temp:. °C) __ Chloride __ Beryllium __ Thallium i __ BOD (5 day) __ Cyanide __ Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Zinc i Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOa CLP __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*^ __ Metals/CN I. * __ Dissolved Oxygen __ Nitrogen, Nitrate as N __ Chromium, Total __ Volatiles I ’ __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Sem i-violatiles __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N __ Cobalt ti- __ Pesticides/PCB’s __ Solids, Percent (%) j_ Oil and Grease __ Copper __ Solids, Settleable __ Phenol __ Iron TCLP 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 __ Other: _ __________________ _ UV254 __ Molybdenum _ TCLP-BNA’s __ Nickel L t ! NYC-WTC_000074366