Chain of custody record, Westchester County Lab, Feb 2002

NYC 9/11 Public Portal Document

I Y

A ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH S 2 Dana Road, Valhalla, New York 10595 (914) 231-1620 Fax (914) 231-1772 NYS-ELAP No. 10108 Time/Date Set: z-tom A-70 (rev. 10/01) if/ r & Sample Type (circle one): 1. Potable 2. Non Potable 3. Non Potable Treated 4. Other Bottle #’s: /t Chain of Custody?___ Yes _ No

Time/Date Collected: Comments:_____________ Agency Code: A /- PWS #:_____ __ Source ID: Type Descriptor: Collected By: Collected From: Bill to:

Location's/lndividual's Name Name/Company S;" Street____________________ Street________

I City/St/Zip________________ Identification of Source City/St/Zip Phone#: Fax#:

Collection Point CA,CH, Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:__________________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS K __ Heterotrophic Plate Count (hemodialysis & all others) __ Trihalomethanes (524) __ Volatile Halocarbons (524) __ Purgeable Halocarbons (624/8260) _ _ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) __ Volatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) __ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081) __ Microextractables (504) _ PCB’s (Arochlors) (608/8081) __ Microscopic __ Pesticides/PCB screen (508) __ Herbicides (SM18/6630,8151)

f __ Macroscopic __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SMI8/6630) _ API _ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) __ Other:________________________

I Refrigerated? yes no __ Pesticides (525) __ Carbamate Pesticides (531) __ Glyphosate (547) __ Glycols in Water _ Acid Extractables (625/8270) ' __ Base Neutral Extractables (625/8270)

feK Chlorinated:? yes___ no Free Chlorine Res:._________mg/L Total Chlorine Res: ________ mg/L __ Diquat (549) __ Chlorination Disinfection Byproducts (551) __ Haloacetic Acids (552) ‘Y GC/MS Unknown Scan __ Phthalates (606MS) __ Other:_______________________________ _Other Pesticides (SMI8/6630) pH __________ _UCMR List 1

FSi RADIOCHEMICAL ANALYSIS ___ Radon _MtBE Only (524)

__ Other_______________________

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ /'cidity __ Aluminum __ Potassium __ Turbidity __ Alkalinity __ Antimony __ Selenium _ pH __ Bromide __ Arsenic __ Silver __ Conductivity __ Bromate/Chlorate/Chlorite I' __ Barium __ Sodium __ Corrosivity (temp:°C) __ Chloride __ Beryllium __ Thallium __ BOD (5 day) __ Cyanide __ Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Zinc 3' _ Soluble BOD (5 day) __ Chemical Oxygen Demand __ Hardness, Total as CaCOa __ Nitrogen, Ammonia as N __ Calcium, as CaCOs __ Calcium, Ca*^ £LP _ 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

w- __ Solids, Seftleable __ Solids, Suspended __ Phenol __ Phosphorus Total as P __ Iron __ Lead ICLP _TCLP-Metals __ Solids, Total __ Phosphorus, Ortho as P __ Magnesium __ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates __ Manganese __ TCLP-Herbicides __ Solids, Total Volatile __ Surfactants __ Mercury __ TCLP-Volatiles __ Other:___________________ __ UV254 __ Molybdenum _ TCLP-BNA’s ’/ -------------- _ Nickel

I NYC-WTC_000074432