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

NYC 9/11 Public Portal Document

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ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH s 2 Dana Road, Valhalla, New York 10595 /■ ■ Iw i< \* i-* (914)231-1620 Fax (914) 231-1772 L NYS-ELAP No. 10108

E Time/Date Set: r ' J? Form A-70 (rev.10/01) ■' * t

f Sample-Type,Jcircle one):

2. Non Potable Potable Treated 4. Other Bottle #’s:

Chain of Custody? Yes ) t"" • •• tC. K £ -i .No •■yh'YTH J ' £.7

>5! Time/Date Collected: /•C Comments: , Collected By: / > . O I *■ Agency Code: PWS #:_________ Source ID: Type Descriptor; g'" J Collected From: Bill to: Location's/lndividual’s Name T-l\ (' I / L- X* Name/Company

Street ________ Street__________

t City/St/Zip Identification of Source City/St/Zip Phone#:________ Fax#: Collection Point______ri_L .-r 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)

I X- Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) >-Volatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) __ Coliform MPN (priv well, raw, stp) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081) __ Fecal Coliform (all samples) __ Microextractables (504) _.PCB’s'(Arochlors) (608/8081)

i __ Microscopic __ Macroscopic __ API __ Other:________________________ __ Pesticides/PCB screen (508) __ PCB as Decachlorobiphenyl (508A) __ Herbicides (515) _ Herbicides (SM18/6630,8151) __ Other Pesticides (SMI8/6630) __ Petroleum Hydrocarbon Scan (310-13) __ Pesticides (525) __ Glycols in Water Refrigerated?yes no __ Carbamate Pesticides (531) _ Acid Extractables (625/8270) __ Glyphosate (547) __ Base Neutral Extractables (625/8270) Chlorinated:? yes no __ Diquat (549) 'ZX- GC/MS Unknown Scan Free Chlorine Res; . mg/L __ Chlorination Disinfection Byproducts (551) __ Phthalates (606MS) Total Chlorine Res: . nng/L __ Haloacetic Acids (552) __ j Other;_______________________________ •T- _ Other Pesticides (SMI8/6630) pH --------------------- ■■ e •■ft i _UCMRList 1 RADIOCHEMICAL ANALYSIS __ MtBE Only (524) ___ Radon __ Other_______________________ /

s INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Acidity / ./ X Aluminum __ Potassium __ Turbidity __ Alkalinity Antimony ^Selenium _ pH __ Bromide Arsenic _/Silver __ Conductivity __ Bromate/Chlorate/Chlorite ' •/ Barium __ Sodium __ Corrosivity (temp:°C) __ Chloride ji" Beryllium Thallium ■ BOD (5 day) __ Cyanide __ Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride jXCadmium , "X-Zinc _ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOa [~CLP __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca+2 _Metals/CN __ Dissolved Oxygen __ Nitrogen, Nitrate as N >LChromium, 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 _L Copper __ Solids, Settleable __ Phenol :■ Iron TCLP __ Solids, Suspended __ Phosphorus Total as P JilLead _TCLP-Metals __ Solids, Total __ Phosphorus, Ortho as P __ Magnesium __ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates _1 Manganese __ TCLP-Herbicides __ Solids, Total Volatile __ Surfactants _1-Mercury i _ TCLP-Volatiles Other: i' _________ _ UV254 JS Molybdenum _ TCLP-BNA’s ^..Nickel

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