Chain of custody record, Westchester County Lab, Feb 2002

NYC 9/11 Public Portal Document i

fi. ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH ■1-- 2 Dana Road, Valhalla, New York 10595 (914) 231-1620 Fax (914)231-1772 f fl X

I 5^ I NYS-ELAP No. 10108 Time/Date Set: I /'Form A;70 (rev. 10/01)

L Sample Type (circle one): 1. Potable , 3. Non Potable Treated Bottle #’s:

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

t p Time/Date Collected:

Collected By:_____________ Collected From: '

Agency Code: Comments: PWS #:_________ Bill to: Source ID: Type Descriptor:

Location's/lndividual’s Name Name/Company Street■■ Street__________ City/St/Zip________ City/St/Zip , Identification of Source Phone#:________ Fax#: • l?fe Collection Point ■ CA.CH, Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS Lab#: rr’- Lab#:___________________________ I* ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count __ Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) (hemodialysis & all others) _ Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) - Volatile Aromatics (524) v __ Acrolein & Acrylonitrile (8260) __ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081) __ Microscopic __ Microextractables (504) _ PCB's (Arochlors) (608/8081) __ Macroscopic __ Pesticides/PCB screen (508) _ Herbicides (SM18/6630,8151) _ API __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SM 18/6630) __ Other:________________________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) __ Pesticides (525) __ Glycols in Water Refrigerated?yes___ no __ Carbamate Pesticides (531) _ Acid Extractables (625/8270) ?s. Chlorinated:? yes___ no __ Glyphosate (547) __ Diquat (549) __ Base Neutral Extractables (625/8270) _ GC/MS Unknown Scan D.: Free Chlorine Res:mg/L Total Chlorine Res:mg/L __ Chlorination Disinfection Byproducts (551) __ Haloacetic Acids (552) _ Phthalates (606MS) __ Other:____________ ___________________ __ Other Pesticides (SM18/6630) pH _____________ _UCMR List 1 RADIOCHEMICAL ANALYSIS _MtBEOnly (524) ___ Radon __ Other_______________________

INORGANIC ANALYSIS REQUESTED - Lab#: / __ Color __ 4cidity • Aluminum __ Potassium __ Turbidity __ Alkalinity .- Antimony __ Selenium _ pH __ Bromide Arsenic __ Silver __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium Corrosivity (temp: °C) __ Chloride __ Beryllium Thallium _ BOD (5 day) __ Cyanide __ Boron __ ! Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium r Zinc _ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOa CLP __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*2 _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 __ 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 I__ TCLP-Herbicides __ Solids, Total Volatile __ Surfactants __ Mercury __ TCLP-Volatiles __ Other:___________________ ■ __ UV254 __ Molybdenum __ TCLP-BNA’s __ Nickel I

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