Chain of custody record, Westchester County Lab, Feb 2002

NYC 9/11 Public Portal Document

.►) ACCo. ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM .JVestchester WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 NYSrELAP No. 10108 Time/Date Set: Form A-70 (rev. 10/01)

Sample Type (circle one); 1. Potable , 3. Non Potable Treated Bottle #’s: 2. Non Potable 4. Other___________ Chain of Custody? Yes No Time/Date Collected: Comments: Collected By: Agency Code: PWS #:________ ___ Source ID: Type Descriptor: Collected From: Bill to: t Location’s/lndividual’s Name Name/Company Street■ Street_________ City/St/Zip _______ City/St/Zip I Identification of Source Phone#:■ Fax#; Collection Point■ CA,CH, Bl? Check#: Arnount$.

I BACTERIOLOGICAL ANALYSIS Lab#: Lab#:_______________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count __ Trihalomethanes (524) (hemodialysis & all others) __ Purgeable Halocarbons (624/8260) __ Coliform P/A (Public supplies) _:^'Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform MPN (priv well, raw, stp) _j:'Volatile Aromatics (524) __ 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 (SMI8/6630,8151) __ API __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SMI8/6630) __ Other:_____________________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) __ Pesticides (525) __ Glycols in Water I Refrigerated?yes___ no __ Carbamate Pesticides (531) _ Acid Extractables (625/8270) Chlorinated:? yes no __ Glyphosate (547) __ Base Neutral Extractables (625/8270) _ Diquat (549) __ 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 (SMI 8/6630) I. pH ___________ _UCMR List 1 I RADIOCHEMICAL ANALYSIS _MtBEOnly (524) __ Radon __ Other____________________

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 _ BOD (5 day) __ Cyanide __ Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride _Cadmium __ ^-Zinc’ _ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOa CLP __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*2 __ Dissolved Oxygen __ Metals/CN __ 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 i __ Solids, Percent (%) __ Oil and Grease __ Copper __ Solids, Settleable __ Phenol __ Iron ICLP. t __ 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 __ TCLP-Volatiles __ Other:_________________ _ UV254 __ Molybdenum _ TCLP-BNA's __ Nickel ! I

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