Chain of custody record, Westchester County Lab, Feb 2002

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM :StEr WESTCHESTER COUNTY LABORATORIES AND RESEARCH I AX'Oni: 2 Dana Road. Valhalla. New York 10595 nelc NYS-ELAP No. 1C108 Time/Date Set: Form AYO (rev.10/01) ■■

I Sample Type {circle one):: 1. Potable :3. Non Potable Treated A / Bottle #'s: .. ...... 2. Non Potable 4. Other ___________ Chain of Custody?: Yes No: Time/Date Collected: Comments: Collected By: _ ___________ _l Agency Code: Source ID: Type Descriptor: Coilected From; Bill to; Location's/lndividual’s Name I Name/Company Street____________________ : Street City/SVZip_________________ : City/St/Zip Identification of Source: Phone#:; Fax#: Collection Point _____ ■___ j CA.CH, Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS Lab#:: Lab#;_______________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOIABLE/SOLID ANALYSIS __ Heterotrophic Plate Count (hemodialysis & all others) __ Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) __ 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) PCB's (Arochlors) (608/8081) __ Macroscopic __ Pesticides/PCB screen (508) Herbicides (SM18/6630,8151) __ PCB as Decachlorobiphenyl {508A) Other Pesticides (SM18/6630) _ API __ Other:: __ Herbicides (515) Petroleum Hydrocarbon Scan (310-13) __ Pesticides (525) __ Glycols in Water Refrigerated?yes no __ Carbamate Pesticides (531) ■ Acid Extractabies (62.5/8270) Chlorinated:? yes no __ Glyphosate (547) Base Neutral Extractables (625/8270) _Diquat (549) i_ GC/MS Unknown Scan Free Chlorine Res:: . . mg/L __ Chlorination Disinfection Byproducts (551) Phthalates (606MS) Total Chlorine Res:. .. rng/L: __ Haloacetic Acids (552) __ Other:___________________ ________ __ Other Pesticides (SMI8/6630) pH ___________ __ UCMRListI RADIOCHEMICAl. ANALYSIS ___ MtBE Only (524) IB __ r/adon __ Other: ,— INORGANIC ANALYSIS REQUESTED - i.,::. - __ Color __ -Acidity _r_ Aluminum __ Potassium _ _ Turbidity __ Alkalinity Antimony Selenium pH __ Bromide Arsenic _ Silver __ Conductivity __ Bromate/Chlorate/Chlorite Barium __ Sodium _ Corrosivity (temp: “C) __ Chloride .iU. Beryllium __ Thallium __ BOD (5 day) __ Cyanide __ Boren __ Vanadium __ Carbonaceous BOD (5 day) Fluoride __ Cadmium __ Zinc Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaC01 __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium. Ca« __ Dissolved Oxygen __ Nitrogen, Nitrate as N __ Metals/CN .iOChromium, Total __ Volatiles __ Total Organic Carbon _ Nitrogen, Nitrite as N Chromium, Hexavalent __ Semi-violatiles __ Total Organic Halides __ Nitrogen. Total Kjeldahl as N X. Cobalt __ Pesticides/PCB's Solids, Percent (%) __ Oil and Grease I/'- Copper __ Solids. Settleable __ Phenol , Iron TCI..P __ 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: ____L_______ UV254 _^Molybdenum __ TCLP-BNAs liisisiiiiiisiiiiii/iiio

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