Chain of custody form, NYC DEP sample AE04802, Feb 2002

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM I" WESTCHESTER COUNTY LABORATORIES AND RESEARCH L' 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 V ■’>

I Time/Date Set:

Sampje Type (circle one): ■r' ‘ Y / V- M f-f NYS-ELAP No. 10108 ' Form A-70 (rev.10/01)

' K-- {1. Potable 3. Non Potable Treated Bottle #’s:

2. Non Potable 4. Other Chain of Custody?____ Yes No ’■ 4 ■ A F 4/-

I Time/Date Collected: Collected By: Collected From: <■ i Agency Code: Comments: PWS #:_______ Bill to: Source ID: Type Descriptor:

Location's/lndividual’s Name Name/Company Street - ir'.. i Street _________ r ■ J

i / - City/St/Zip \ i ( .'-I 7 City/St/Zip

F Identification of Source Phone#; Fax#;

I' Collection Point / /' i 6-- / / CA.CH, Bl? Check#: Amounts

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:__________________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count __ Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) (hemodialysis & all others) _YVolatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) ftp" __ 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)

k. __ Macroscopic _ API __ Pesticides/PCB screen (508) __ PCB as Decachlorobiphenyl (508A) __ Herbicides (SM18/6630,8151) __ Other Pesticides (SMI8/6630)

F __ Other:_______________________

Refrigerated?yes___ no __ Herbicides (515) __ Pesticides (525) __ Carbamate Pesticides (531) __ Petroleum Hydrocarbon Scan (310-13) __ Glycols in Water _ Acid Extractables (625/8270)

E Chlorinated:? Free Chlorine Res:mg/L Total Chlorine Res:mg/L yes___ no __ Glyphosate (547) __ Diquat (549) __ Chlorination Disinfection Byproducts (551) __ Haloacetic Acids (552) __ Base Neutral Extractables (625/8270) _>GC/MS Unknown Scan ' Phthalates (606MS) __ Other:_______________________________

j pH _____________

RADIOCHEMICAL ANALYSIS __ Other Pesticides (SM18/6630) _UCMR List 1 __ MtBE Only (524) I

___ Radon I __ Other_______________________

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Acidity JY Aluminum __ Potassium __ Turbidity __ Alkalinity Antimony ^-Selenium _ pH __ Bromide Arsenic ^-Silver __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium -^Sodiurn- __ 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 I _ Metals/CN __ Dissolved Oxygen __ Nitrogen, Nitrate as N .2S_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 __ Solids, Percent (%) __ Oil and Grease' >■ Copper __ Solids, Settleable __ Phenol Iron TCLP __ 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 'iS'-Other;\ ' _ TCLP-Volatiles _ UV254 Molybdenum i_ TCLP-BNA's Nickel

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