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

NYC 9/11 Public Portal Document

►t ,>» 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 NYS-ELAP No. 10108 . Time/Date Set: / Form A-70 (rev. 10/01) -------------- Sample Type {circle one): 1. Potable 3. Non Potable Treated Bottle #'s: s; / 2.,Non Potable 4. Other. Chain of Custody? Yes___ No f Time/Date Collected: /7 Comments:

f A' Collected By:l Collected From: Location’s/lndividual’s Name Street_________________ Agency Code: •' I .. ’ ■/ - J/- PWS #:________ Bill to: Name/Company Street_________ Source ID: Type Descriptor;

r City/SVZip______________ Identification of Source Collection Point City/St/Zip Phone#;_______

CA,CH, Bl? Check#: Fax#:

Amounts,

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:_______________________ / ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count __ Trihalomethanes (524) __ Purgeable Halocarbons (624/8260)

t (hemodialysis & all others) __ 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) __ 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) A./ Chlorinated:? yes___ no __ Glyphosate (547) ___Base Neutral Extractables (625/8270) __ Diquat (549) >-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) I pH ___________ : RADIOCHEMICAL ANALYSIS _UCMR List 1 __ MtBE Only (524) __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Acidity __ Aluminum __ Potassium __ Turbidity __ Alkalinity __ Antimony __ Selenium _ pH __ Bromide __ Arsenic __ Silver __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium __ Corrosivity (temp;. °C) __ Chloride __ Beryllium __ Thallium __ BOD (5 day) __ Cyanide __ Boron __ Vanadium I __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Zinc _ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOa cTp __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca+2 _ Metals/CN .__ Dissolved Oxygen __ Nitrogen, Nitrate as N __ 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 J __ Solids, Settleable '__ Phenol __ Iron __ Solids, Suspended TC-LP __ 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:_________________ _ UV254 __ Molybdenum _ TCLP-BNA's __ Nickel

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