Chain of custody record, Westchester County Lab, Feb 2002

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM esk'f WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 NYS-ELAP No. 10108 Time/Date Set- Form'A-70 (rev. 10/01)

P T Boitio

2. Non Potable 4, Other Chain of Custody?- 'es No v-Time/Date Collected: Comments: Collected By; .w 7 f fc Agency Code;___ : PWS #;_________ : Source ID: Type Descriptor:

Collected From: Bill to;

Location’s/lndividual’s Name: Name/Company

Street____________________ Street;

City/St/Zip__________________ _ City/SVZip Identification of Source Phone#:________ _ Fax#: Collection Point♦ v Y-r k..'..f ) I CA,CH, Bl?: Check#:: Amounts

BACTERIOLOGICAL ANALYSiS Lab#:: Lab#:__________________________ _ i ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOl ID ANALYSIS __ Heterotrophic Plate Count __ Trihalom^h^nes (524) __ Purgeable Halocarbons (624/8260) (hemodialysis & all others) __ Volatile Halocarbons (524) ___ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) __ Coliform YPN (priv well, raw, stp): __ Volatile Aromatics (524) Acrolein & Acrylonitrile (8260) __ Fecal Coliform (ail samples) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/808 I) • .. . Microscopic __ Microextractables (504) PCB’s (Arochlors) (608/8081) Macroscopic __ Pesticides/PCB screen (508) Herbicides (SMI 8/6630.8151) __ PCB as Decachlorobiphenyl (508A) Other Pesticides (SMI8/6630) API

I __ Other:_______________________ _

Refrigerated? yes___ no __ Herbicides (515) __ Pesticides (525) __ Carbamate Pesticides (531) __ Glyphosate (547) Petroleum Hydrocarbon Scan (310-13) __ Glycols in Water Acid Extractables (625/8270) __ .Base Neutral Extractables (625/8270) Chlorinated:? yes no __Diquat (549) A'"gC/MS Unknown Scan Free Chlorine Res:mg/L ■■ Total Chlorine Res:mg/L __ Chlorination Disinfection Byproducts (551)^ __ Haloacetic Acids (552) Phthalates (606MS) Ottier:_______________________________ __Other Pesticides (SMi 8/6630) pH_____________ _ UCMR List 1

Bl ___ Radon RADIOCHEMICAL ANALYSIS^ _ MtBE Only (524)

__ Other_ , ■ INORGANIC ANAt-VSIS REQUESTED - L.ih# __ Color __ Acidity Aluminum: __ Potassium I __ Turbidity pH __ Alkalinity __ Bromide je,'Antimony I Arsenic _L-§elenium ___^-Siiver __ Conductivity __ Bromate/Chlorate/Chlorite Jt'Barium __ Sodium __ Corrosivity (temp;: °C): __ Chloride V Beryllium _V'thallium __ BOD (5 day) __ Cyanide __ Boron __ Vanadium Carbonaceous BOD (5 day) __ Fluoride __ Cadmium Affine Soluble BOD (5 day) __ Hardness, Total as CaCO:: __ Calcium, as CaCO;j __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca« j^-jjChromium, Total _ Metals/CN __ Dissolved Oxygen __ Nitrogen, Nitrate as N _ Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent Bl III __ Total Organic Halides Solids, Percent (%) __ Nitrogen. Total Kjeldahl as N __ Oil and Grease J^Cobalt V^Copper __ Semi-violatiles __ Pesticides/PCB's

__ Solids, Settleable __ Phenol .kdron f _ Solids, Suspended __ Solids, Total __ Phosphorus Total as P __ Phosphorus, Ortho as P JkfLead __ Magnesium TCLP _TCLP-Metals __ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates 4zManganese __TCLP-Herbicides Solids, Total Watile __ Surfactants .iTMercury TCLP-Voiatiies ■ Jef Other: «□/?________ iiililllliliillllllillB iZ Molybdenum _ TCLP-BNA’s J|Z Nickel

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