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

NYC 9/11 Public Portal Document

environmental SERVICES SAMPLE SUBMISSION FORM II* ^CQm WESTCHESTER COUNTYiJKBORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595'" (914)231-1820 Fax (914) 231-1772 >1 NYS-ELAP No. 10108 r Time/Date Set: FonnA-70(rev.10/01)

Sample Type (circle one): ^Potable 3. Non Potable Treated Bottle #’8: K. Non Potable 4. Other__________ ; _ Chain of Custody? _ Yes No J k Tlme/Date Collected: „ _ Comments: _____ TypeDescript^ Collected By: Agency Code: ____ _ PWS #:_____ Source ID; Collected From: X/' -.,4 Bill to:

I Location’s/lndlviduars Name - < street M._________ . ■ _

-_ W- Name/Company

— I ; City/S^p_________ Identification of Source Ci^/St/Zip_____ _ 3. j<^lTK^e#: ______ _Fax#;_ «

I Collection Point -B' I CA.CH. Bl? / Amoiii^ ■ ■■

BACTERIOLOGICAL ANALYSIS: B __ Heterotrophic Plate Count V Lab#:,_____________ Lab#: 7? ORGANICPOTABL<ANALYSIS ..... ■ 'M/-/ .......... .....V- ORGANIC NONPOTABLE/SOLID ANALYSIS - Y.- ■.<

I (hemodialysisSail others) _ Coliform PZA (Public supplies)- ’ _TrihaIdrhethanes^24) _ Volatile Halocar®s (524) ' ■> -- ___Purgeable Halocarbons (624/8260) Purgeable Arahtetics (824«280) , /ill I I?' __ Coliform MPN (priv well, raw, ^) 2.2. Fecal Coliform (all samples) ; .22 Microscopic. „ Macroscopic 2^ _ Vblaflle Arom^ (524) _ Total Trihalom^ane Potential (510) _ Microextractabfes(5p4) _Pesticides/PC&scre8n(508) _ Acroleins Acrylonitrile (8260) _:OiganochlorlnsP8Stlcldes (608/8081) _2’gCfa(AfbcO2 22»loic^^.(pt.8(8^15T)2-^- i i

2# ^3 _ Oth8E pest{c(de8 (SM18/6630) yO 3 i I - y 2;. Api ' __ Other_ _______ " T" _ PCB as Decachlorobiphenyl (508A) _ RiBlddea (515)^ _2.petrdldbiHydrocarbon Scan ^IM^W a _i Qlwols in Water 5 1 Refrigerated? yes ___ no _^^Btracfables (625/8270) ’ ,53,) B-f :««i

_ Glyphosate (^j - _<Ba^ Neutral Extractables (825/8270) Chlorinated;?.ye8_U-no^,, '1 Free Chlorine Re8:__^__ mg/L _Diquat (549) Ml- . __ Chlorination Disinfection Byproducts (551) __Phthaiate8(606MS) X

II Total Chlorine Res:mg/L

Y ,RADIOCHEMICAL ANALYSIS _ __ Hsdoacetic Acids (552) /. other Pesticides (SM18/6630) UCMRlisttl MtBE Only (S24) ' ' ■

22J^n' B15' 22'^Other'______ __________ ... 2^^ JNORGANIC ANALYSIS REQUESTED < Lab#; ’ 2 i^iS^'Cdipr Aridity jCAfuminum _ Potassiur । *2_ Turbidity ' _ Alkalinity ±C’^tlmony :^^^ienfurni = - W W- ^•pH/- - ■ \^Brdmide ±r2^rsenic .s^SIlver/S -2- ■2- Conductivity _ Bromate/Chlorate/Chlorite J^oarium C- Corrosivity (temp:____ .°C) _ Chloride jsi^fe^^lium ji^nTialllum ■•2 . „ BOD (5 day) _Cyanide _Boron\''' /v ;. _yanadfur 2_ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium \ i^riciX>| . 1

I X_ Soluble BOD (5 day) _ Hardness, Total as CaCOs _ Calcium,as CaCOs _ Chemical Oxygen Demand __ Nitrogen, Ammonia as N _Calcium,Ca*2 __ Dissolved Oxygen _Metals/CN ' _ Nitrogen, Nitrate as N jYChromium, Total < _ Vblatlles, ■ ■..

I _ Total Organic Carbon __ Total Organic Halides Solids, Percent (%) Solids, Settleable _ Nitrogen, Nitrite as N _ Nitrogen, Total Kjeldahl as N __ Oil and Grease Phenol i> _ Chromium, Hexavalent ' ^Cobalt jiCopper j^iron _Semi-violatlles PestIcldes/PCB’s >’

Sf;’-'

'W' Solids, Suspended . _ Solids, total _ 'Solids>Total Dissolved 2.2’Solid8<TbmVbIatlle __ Phosphorus Total as P _ Phosphorus, Ortho as P _ Sulfates __ Surfactants • _^ead __ Magnesium j^Manganese ■' ■/ , _TCLP-Metals _TCLP-Pesticides __TCLP-Herbicides i £ Other: .J»v- UV254 ±rMercury ^Mdybdenum _TCLP-VQlatiles _ TCLP-BNA's Z jifNickel ..i AAs'i/i

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