Chain of custody form, NYC DEP sample AE04843, Feb 2002

NYC 9/11 Public Portal Document fe ■■ iff xeeoA 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-ELAPN0HOIO8 S 1/ i V.,- Time/Date Set:

Sample Type (circle one): 1. Potable 3. Non Potable Treated Bottle #'8: Hi? Form Ar76 (rev.10A)1) ;;

2. Non Potable 4. Other Chain of Custody? Yes _ No Comments: I. Ume/Date Collected: _____ Collected By:;__________ Agency Code: PWS#:____^X.4Swjfde ID: . Type Descriptor: ,

I Collected From: Location's/Individual’s Name "/.Street _________ Bill to: Name/Company Street______ City/St/Zip _______ City/St/Zip___ Identification of Source Phone#:______ _ Collection Point Y 4^ \> CA.CH, Bl?_—XTiXenbck#: i, Amount$_ S'; BACTERIOLOGICAL ANALYSIS Lab#:_ J Lab#: __________ I' __ Heterotrophic Plate Count ORGANIC POTABLE ANALYSIS _ Trihaiomethanes (524) ORGANIC NONPOTABLE/SOLID ANALYSIS ' _^ '. P^ .1

r'I (hemodialysis & all others) __ Coliform P/A (Public supplies) __ Volatile Halocarbons (524) _ Pufgeable Aromatics (624/8260) ’ .8 _ _Coliform MPN (priv well, raw, stp) __ Volatile Aromatics (524) ;_ Acroleln & Acrylonitrile (8260) __ Fecal Coliform (all samples) ___ Total Trihalomethane Potential (510) _ .Microscopic __ Microextractables (504) X PCffs (Arochlor^) ,(8(W)811' ?

I Macroscopic -iAP* _ Other. _ Pestlcides/PCB screen (508) _ PCB as Decachlorobiphenyl (508A) __ Herbicides (515) __ Pesticides (525) _P0troleumHydrocarbonScan(31O-13)

Refrigerated? yes___ no __ Carbamate Pesticides (531) _ AcIdExtractables (625/8270) j i? E Ch&nated:?___ yes _ no Free Chlorine Res:_______ mg/L _ Glyphosate (547) __Diquat (549) - _ Chlorination Disinfection Byproducts (551) — Base Neutral Extractables (625/8270)

XPhtharate8(606MS) as-- Total Chlorine Res:mg/L _Haloacetic Acids (552) other.. _ Other Pesticides (SM18/6630) pUx-_—______ __UCMRLIst1 Ji RADIOCHEMICAL ANALYSIS __MtBE Only (524) ' __R^on iJ *K . _ Other. -XlS-XX -.■YY. INORGANIC ANALYSIS REQUESTED - Lab#: — Color _ Acidity __ Aluminum ■■■'/ # '' Potassium ''s; -Turbidity _ Alkalinity _ Antimony • ‘ YY:S<^hium

I _ pH __ Bromide __ Arsenic % /Y " ^_JSilvet- ' ■■■ __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium. , '7 — Sodium __ Corrosivity (temp:®C) _ Chloride — Beryllium ' . ;:y'.YXThaliiurn.j, — BOD (5 day) _ _Cyanide ;_ Boron —Vanadiurp __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium 777 — Soluble BOD (5 day) __ Hardness, Total as CaCOa _ Calcium, as CaCOs __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N — Calcium, Ca^,;;Y __ Dissolved Oxygen __ Nitrogen, Nitrate as N __ Chromium, Total, __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent ' ' S-'?; 'XMbliM--,; X^ml’waflies __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N —Cobalt •' 7/ ; — Pes«cid|s/PCB's __ Solids, Percent (%) __ Oil and Grease __ Copper ' __ Solids, Settleable __ Phenol __ Iron W-. -.I ' r __ Solids, Suspended __ Solids, Total __ Solids, Total Dissolved — Solids, Total Volatile __ Phosphorus Total as P __ Phosphorus, Ortho as P __ Sulfetes __ Surfactants — Lead — Ms^nesium, Y' __ Manganese; __ Mercury .i2iTCLPrM8tals; _TCLP-Pestlcldes _TCLP-Herbicides _ TCLP-Voiatiies

i __ Other._______________ _ _ UV254 __ Moiybd^um __TCLP-BNA’s -Nickel

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