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 IfljEfeOV NYS-ELAP No. 10108 jTime/Date Set: Form A-70 (rev. 10/01) •

Sample Type (circle one): si'. ! 1. Potable I/-"-", 3. Non Potable Treated Bottle #’s: EIlZL (i yzo /' 2. Non Potable 4. Other________ < Chain of Custody?Yes No i Time/Date Collected: ■ -I Comments:____________ 5 ' „ Vx ' Collected By: Agency Code: PWS #:______ Source ID: Type Descriptor: .Collected From: Bill to: jLocation's/lndividual’s Name f i4 Name/Company ' Street_________________ Street_______ fCity/SVZip______________ City/St/Zip lldentification of Source Phone#: Fax#: ‘Collection Point r H'J I' I CA,CH, Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:___________________ I ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS J_ Heterotrophic Plate Count __ Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) (hemodialysis & all others) __ Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) fe- Coliform P/A (Public supplies) I Coliform MPN (phv well, raw, stp) __ Volatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081) p§, . Fecal Coliform (all samples) ' Microscopic __ Microextractables (504) __ Pesticides/PCB screen (508) _ PCB's (Arochlors) (608/8081) _ Herbicides (SM18/6630,8151) _ Macroscopic _L API __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SMI8/6630) _ Other:____________________ __ 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) p. v/ GC/MS Unknown Scan __ Diquat (549) Free Chlorine Res:mg/L __ Chlorination Disinfection Byproducts (551) C Phthalates (606MS) Total Chlorine Res:mg/L __ Haloacetic Acids (552) __ Other;____________________________ __ Other Pesticides (SMI8/6630) pH ___________ _UCMR List 1 [RADIOCHEMICAL ANALYSIS _ MtBE Only (524) __ iRadon __ Other____________________ ft

INORGANIC ANALYSIS REQUESTED - Lab#; ■' Color __ Asidity __ Aluminum __ Potassium __ Turbidity __ Alkalinity __ Antimony __ Selenium ! > pH __ Bromide __ Arsenic __ Silver _ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium

s ' Corrosivity (temp:, • BOD (5 day) __ Carbonaceous BOD (5 day) _ Soluble BOD (5 day) .°C) __ Chloride __ Cyanide __ Fluoride __ Hardness, Total as CaCOs __ Beryllium __ Boron __ Cadmium __ Calcium, as CaCOs __ Thallium __ Vanadium __ Zinc I

CLP _ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*2, S’ _ Metals/CN ' Dissolved Oxygen __ Nitrogen, Nitrate as N __ Chromium, Total __ Volatiles __ 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 _1 Solids, Settleable __ Phenol __ Iron TCLP __ 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 _ 1 Solids, Total Volatile __ Surfactants __ Mercury _TCLP-Volatiles __ Other;_________________ _ UV254 __ Molybdenum _ TCLP-BNA's __ Nickel

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