Chain of custody record, Westchester County Lab, Feb 2002

NYC 9/11 Public Portal Document I

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ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 I .f o X I (914) 23M620 Fax (914) 231-1772 NYS-ELAP No. 10108 jTime/Date Set: Form A-70 (rev. 10/01)

Sample Type (circle one). .1 /■ ml h. Potable ' 2. Non Potable 3. Non Potable Treated 4. Other, Bottle #’s: ___________ ______ Chain of Custody?_ L Yes___ No -M Time/Date Collected: Comments: j'Collected By: Collected From: t ' Agency Code: '<-'i > PWS #:______ Bill to: Source ID:. Type Descriptor: 31 Location’s/lndividual’s Name Name/Company J

i Street_________________ Street_______ J 'City/St/Zip______________ Identification of Source City/St/Zip Phone#: Fax#: I [Collection Point r f-7/ ? Amounts. CA,CH, Bl? Check#: I

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:_______________________ 3 ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS ' . Heterotrophic Plate Count __ Purgeable Halocarbons (624/8260) ’ » (hemodialysis & all others) __ Trihalomethanes (524) J_ Coliform P/A (Public supplies) __ Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) I Coliform MPN (priv well, raw, stp) __ Volatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) _L Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) __ Microextractables (504) __ Organochlorine Pesticides (608/8081) ' __ PCB’s (Arochlors) (608/8081) 1 __ Microscopic i J_ Macroscopic __ Pesticides/PCB screen (508) _ Herbicides (SM18/6630,8151) _ API __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SMI8/6630) __ Other:_____________________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) ‘=1 I __ Pesticides (525) __ Glycols in Water I' Refrigerated?yes___ no __ Carbamate Pesticides (531) __ Acid Extractables (625/8270) Chlorinated:? I yes no __ Glyphosate (547) __ Diquat (549) __ Base Neutral Extractables (625/8270) •' GC/MS Unknown Scan I Free Chlorine Res:mg/L __ Chlorination Disinfection Byproducts (551) _ Phthalates (606MS) Total Chlorine Res:mg/L __ Haloacetic Acids (552) Other:__________________________ _ __ Other Pesticides.(SMI8/6630) pH ___________ __ UCMRListI RADIOCHEMICAL ANALYSIS _ MtBE Only (524) 1. _ iRadon __ I Other____________________ '4 INORGANIC ANALYSIS REQUESTED - Lab#: J_ Color •J- __ Acidity __ Aluminum _ Potassium > __ Turbidity __ Alkalinity __ Antimony I Selenium _L pH __ Bromide __ Arsenic __ Silver 1 Conductivity __ Bromate/Chlorate/Chlorite • __ Barium __ Sodium * Corrosivity (temp:. .°C) __ Chloride __ Beryllium __ Thallium 1 J_ BOD (5 day) __ Cyanide, __ Boron __ Vanadium _L Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Zinc I Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOs CLP __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca-*^ _ Metals/CN __ Dissolved Oxygen __ Nitrogen, Nitrate as N __ Chromium, Total __ Volatiles _ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent f __ Semi-violatiles I ! Total Organic Halides _ _ Nitrogen, Total Kjeldahl as N .__ Cobalt __ Pesticides/PCB's I Solids, Percent (%) __ Oil and Grease __ Copper I ■ Solids, Settleable __ Phenol __ Iron 4 tclp t Solids, Suspended __ Phosphorus Total as P __ Lead _TCLP-Metals _L Solids, Total __ Phosphorus, Ortho as P __ Magnesium __ TCLP-Pesticides _! Solids, Total Dissolved __ Sulfates Manganese __ TCLP-Herbicides Solids, Total Volatile __ Surfactants __ Mercury _ TCLP-Volatiles _f Other:_________________ _ UV254 __ Molybdenum _ TCLP-BNA’s i ------------ __ Nickel 1

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