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

NYC 9/11 Public Portal Document

ACCo ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 *? ^f\ c r f Time/Date Set:

Sample Type (circle one): T J J NYS-ELAP No. 10108 ^Form A-70 (rev. 10/01)

f; \ 1. Potable > 3. Non Potable Treated Bottle .\fes No V. i-t

s 2. Non Potable 4. Other _ __________ Chain of Custody? Time/Date Collected:. ■" } n • ft , Comments: Collected By: ' > u Agency Code: PWS #:________ Source ID: Type Descriptor: Collected From: Bill to: V- Location’s/lndividual’s Name Name/Company Street (.AH.,- .'V , Street_________

I: I City/SVZip Identification of Source S' City/St/Zip Phone#:_______ Fax#: Collection Point CA,CH, Bl? Check#:; Amounts.

t BACTERIOLOGICAL ANALYSIS Lab#;_______________________ Lab#:

ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count .1 (hemodialysis & all others) __ Trihalomethanes (524) Volatile Halocarbons (524) __ Purgeable Halocarbons (624/8260) __ Purgeable Aromatics (624/8260) .._ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, sip) 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 (SMI 8/6630,8151) ■_ API __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SM18/6630) __ Other:_____________________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) __ Pesticides (525) __ Glycols in Water ' Refrigerated?yes no __ Carbamate Pesticides (531) __ Acid Extractables (625/8270) Chlorinated:? yes no __ Glyphosate (547) __ Base Neutral Extractables (625/8270) ft. __ Diquat (549) _4 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 RADIOCHEMICAL ANALYSIS _MtBEOnly (524) __ Radon __ Other____________________ / INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Acidity ""'Aluminum __ Potassium __ Turbidity __ Alkalinity Antimony 2:1 Selenium _ pH __ Bromide A Arsenic Silver __ Conductivity __ Bromate/Chlorate/Chlorite _X Barium __ Sodium __ Corrosivity (temp:. °C) __ Chloride Beryllium Thallium __ BOD (5 day) __ Cyanide __ Boron _i_ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride X. Cadmium •A .Zinc __ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOa “CLP A- __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca^2 _ Metals/CN __ Dissolved Oxygen __ Nitrogen, Nitrate as N _^Ghromium, Total __ Volatiles Jr __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Semi-violatiles __ Total Organic Halides _ Nitrogen, Total Kjeldahl as N ftiCobalt _ Pesticides/PCB’s

I __ Solids, Percent (%) __ Solids, Settleable __ Solids, Suspended __ Solids, Total __ Oil and Grease __ Phenol __ Phosphorus Total as P __ Phosphorus, Ortho as P ft. Copper ft Iron Lead __ Magnesium TCLP __TCLP-Metals __ .TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates 2i_ Manganese __ TCLP-Herbicides __ Solids, Total Volatile __ Surfactants " Mercury _ TCLP-Volatiles Other:______ ILLu_____ _ UV254 2L' Molybdenum _ TCLP-BNAs ft,Nickel ■e

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