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

NYC 9/11 Public Portal Document

«« ACCo.' ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2D^ Rpad, Valhalla, New York 10595 s ^914) 231-1620 Fax (914) 231-1772 NYS-ELAPNo. 10108 Tlme/Date Set: Form A-70 (rev.10/01) . 7^ 4 < t': t^^ Sarriplejype Pptabie . (circle one): 3. Non Potable Treated Bottle #’s: fP ' z fz/ 2. Non Potable 4. Other _ _____________________ Chain of Custody? Yes No

E Tlme/Date Collected: Collected By:XMi££__ Collected From: 7 w ■-g 2__± Agency Code::

_ Comments: PWS #:__________ _ Source ID: Bill to: Name/Company .Type Descriptor:.

Locatlon's/lndividual’s Name Street________________ _ Street_______ ___ I?: City/St/Zip _ ___________ -r _ City/St/Zip ,p Identification of Source,__ _ Phone#: ____ (^Hectlon Point __ 5^11x2 I CA,CH, Bl? Check#; _Amount$ I I BACTERIOLOGICAL ANALYSIS Lab#:

i9 ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLlDANALYSIS __ Heterotrophic Plate Count _Trlhalomethane8 (524) _ Purgeable Halocarbons (624/8260) ;/JChemodlalysis & ail others) Coliform P/A (Public supplies) _ Volatile Halocarbons (524) _ Pui^eable Aromatic® (624/8260) r 2_ Coliform MPN (priv well, raw, stp) __ Fecal Coliform (all samples) _ Volatile Aromatics (524) _ Total Trlhalomethane Potential (510) _ Acrolein & A|yl6nitrile‘(8260) / _ OrganochlorineP0sticides (6O8/8O81) •3

I' ;:^jWicroscoplc _ Microextractawes (504) _ PCB’s (Arochlors) (608/8081) ) M Macroscopic _ Pesticides/PCB screen (508) _ Herbicides (SM18/6630,8151) 'BzApr' _PCB asD^chlorobiphenyl (508A) ■ _ Other Pestlcides (SM18/6630) M/Othen__ _______ _HerWcldes (515) _ Pe.troleum Hydrocarbon Scan (310-13) O _ Pesticides (525) _ Glycols in Wdter . Refrigerated?----- yes no _ Carbamate Pesticides (531) . _ WExO^I^/(6^70t-- r- . -O Chlorinated:?yes K7 FreeChlorIne Res:___ no -mg/L ' _ ; Glyphosate (547) _piquat (549) j_dhlorlnation Disinfection Byproducts (551) Neutral Extractables (625(8270) YfOC/MS UnknownScan: _Phtha!ates(606MS) ; ' ■' Ms TotalChlorlne Res: _Haloacetlc Acids (552) — Other:Xil£4-2-Mi~_; _ Other Pesticides (SM18/8630) _UCMRLi8t1 RADIOCHEMICAL ANALYSIS _MtBE Only (524) fe —Radon

I iC ANALYSIS REQUESTED - Lab#: :

OHS’4 6 Mi _ Turbidity .;_.:ipH ; __ Acidity ±_ Alkalinity _ _Bromide _i'Aluminum _>Antfmony Arsenic sj’um ?■ 4 II Conductivity __ Bromate/Chlorate/Chiorite uL Barium _ Corroslvity (temp:°C) _ Chloride __ Beryllium ■gthafc BOD (5 day) __ Cyanide _ Boron „ Van^lum _ _ Carbonaceous BOD (5 day) __ Flupride __ Cadmium ft — Soluble BOD (5 day) _ Hardness, Total as CaCOs __ Calcium, as CaCOs Chemical Oxygen Demand __ Nitrogen, Ammonia as N _ Calcium, Ca*2 — Dissolved Oxygen 'M4:MefalsZCN// T I

I _ _Nitrogen, Nitrate as N _Chromium, Total __ Total Organic Carbon _ Nitrogen, Nitrite as N _ Chromium, Hexavalent _nSemlA/idlaflles i __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N jjfCobalt — Solids, Percent (%) — Pestlcides/PCB's _ Oil and Grease _ Copper — Solids,,Settleable _ Phenol _:_lron — Solids.; Suspended tClp

i __ Phosphorus Total as P Lead . -Solids; Total —TCLP-Metals Phosphorus, Ortho aS P ' JEMP Mas---- DinlliUm -■•1

— Solids, Total Dissolved —TCLP-Pestlcldes _ Sulfates j^Manganese

I —TCLP-Herbicides __ Surfactants ■^Mercury — TCLP-Votatiles ■ ■ \ _ UV254 ____________________________________________________________________ __________________________________________________________________ j^^rMdybdenun — TCLP-BNA’s . _2fNlckel

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