Chain of custody record, Westchester County Lab, Feb 2002

NYC 9/11 Public Portal Document

A* ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH I 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 o I Time/Date Set; t' NYS-ELAP No. 10108 Forrn A-70 (rev. 10/01)

I- Sample Type (circle one): 1. Potable ^ 3. Non Potable Treated ",

*' ", ■.

' Bottle #’s:_ U 7 i

Is 2. Non Potable 4. Other_____________ Chain of Custody?___ Yes No

I Time/Date Collected: Collected By: / ■J

Agency Code: ‘'7 Ct. Comments: PWS #:_______ Source ID: Type Descriptor:

F Collected From: Location's/lndividual’s Name Bill to: Name/Company

II- Street , i

City/St/Zip f t i i-

, H ■ / Street_________ City/St/Zip

r. Identification of Source Phone#: . Fax#:

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

I BACTERIOLOGICAL ANALYSIS Lab#:___________________________ Heterotrophic Plate Count Lab#:

ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) (hemodialysis & all others)

I. _ji>'Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) _X-Volatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) __ Fecal Coliform (all samples) Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081)

I" __ Microscopic __ Macroscopic _ API _ Other:_______________________ __ Microextractables (504) __ Pesticides/PCB screen (508) __ PCB as Decachlorobiphenyl (508A) __ Herbicides (515) __ PCB’s (Arochlors) (608/8081) _ Herbicides (SM18/6630,8151) __ Other Pesticides (SM18/6630) __ 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) __ Diquat (549) r.-’-GC/MS Unknown Scan Free Chlorine Res: . mg/L __ Chlorination Disinfection Byproducts (551) _ Phthalates (606MS)

FK" Total Chlorine Res: pH _____________

RADIOCHEMICAL ANALYSIS . mg/L __ Haloacetic Acids (552) __ Other Pesticides (SM18/6630) __ UCMR List 1 _MtBEOnly (524) __ Other:________________________________

FI. ___ Radon __ Other_______________________

INORGANIC ANALYSIS REQUESTED - Lab#: •■V- __ Color __ Acidity ^Aluminum __ Potassium __ Turbidity __ Alkalinity _!L^Antimony -■ .Selenium _ pH __ Bromide _L-Afsenic r Silver __ Conductivity __ Bromate/Chlorate/Chlorite _jL-Barium _L Sodium ___ Corrosivity (temp: .“C) __ Chloride _^,Beryllium _<.Thallium _ BOD (5 day) __ Cyanide _1 Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride j£_ Cadmium /—Zinc .__ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOa CLP __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*2 _ Metals/CN __ Dissolved Oxygen __ Nitrogen, Nitrate as N JjiChromium, Total __ Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Semi-violatiles __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N jifCobalt __ Pesticides/PCB’s __ Solids, Percent (%) __ Oil and Grease .^Copper __ Solids, Settleable __ Phenol ■■.<lron TCLP __ Solids, Suspended __ Phosphorus Total as P _L.Lead __ 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 irf'Other: J! _ UV254 Molybdenum _ TCLP-BNA's _ Nickel

NYC-WTC_000074433