Chain of custody record, Westchester County Lab, Feb 2002

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM IB <1. WESTCHESTER COUNTY LABORATORIES AND RESEARCH S5 »■

MYS-ELAPNo. 10108 nme/Date Set: /,, Form A-70 (rev.10/01)

Sample Type (circle one): , 1^,.Potable 3. Non Potable Treated Bottle #'s: Z Non Potable 4. Other _ Chain of Custody? Yes No: Time/Date Collected: Comments:

Collected By: ' ' Agency Code: ||Bl||||||||l|i Source ID: Type Descriptor: Collected From: Bill to: Location's/lndividual's Name Name/Company Street____________________ Street: City/StZZip________________ : City/St/Zip: Identification of Source Phone#:: Fax#: Collection Point CA,CH, Bl?^ Check#: Amoufit$

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:: ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS _ Heterotrophic Plate Count __ Trihalomethanes (524) Purgeabie 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) __ Acrolein & Acrylonitrile (8260) __ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) _ _ Organochlorine Pesticides (608/8081) __ Microscopic __ Microextractables (504) RGB’s (Arochlors) (608/8081) __ Macroscopic __ Pesticides/PCB screen (508) Herbicides (SM18,'6630,8151) __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SMI8/6630) _ API __ Other:: __ Herbicides (515) Petroleum Hydrocarbon Scan (310-13) __ Pesticides (525) Glycols in Water Refrigerated?yes: no __ Carbamate Pesticides (531) __ Acid Extractabtes (625/8270)

■ Chlorinated;? yes no _ Glyphosate (547) __ Base Neutral Extractabtes (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 (SM18/6630) pH_____________ _ UCMR List 1 __MtBE Only (524) ■ RADIOCHEMICAL ANALYSIS ___ Radon __ Other.:

■l INORGANIC ANALYSIS REQUESTED - La:.. II Color _ Acidity llijiiiji __ 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 CaCOa __ Calcium, as CaCO3 __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*2 __ Metais/CN __ Dissolved Oxygen __ Nitrogen, Nitrate as N __ Chromium, Total __ Volatiles __ Total Organic Carbon _ Nitrogen, Nitrite as N __ Chromium, Hexavalent’ __ Semi-violatiles iOi __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N) __ Cobalt __ Pesticides/PCB's II __ Solids, Percent (%) __ Oil and Grease __ Copper

!■ ii __ Solids, Settleable __ Solids, Suspended __ Solids, Total __ Phenol __ Phosphorus Total as P __ Phosphorus, Ortho as P __ Iron __ Lead __ Magnesium I.CLP __TCLP-Metals ■II ! Solids, Total Dissolved __ Sulfates __ Manganese __ TCLP-Pesticides __ TCLP-Herbicides __ Solids, Total Volatile __ Surfactants __ Mercury __ TCLP-Voiatiles _ Other: -______________ : _ Molybdenum _ TCLP-BNA’s ... Nickel ifciii

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