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

NYC 9/11 Public Portal Document r ■ - ■ ■ ■■''

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. 40106 '

i Tlme/Date Set:

SdinpIeType (circle one): 7 ^orfh"A-70(rev.10/01)

Potable 3. Non Potable T/eated ■ Bottle ■^2. Non Potable 4. Other ______ . / _ Chain of Custody? .YiBS__NQ Time/Date Collected? Comments: r Collected By: Agency Code: ______ _ PWS Source ID: .Type Descriptor: I. CoilectedFrom: Location’s/lndividuars Name Narne/Gompany J gStreet2_21.____________.^_______l___- '' Street ’ " l. I Clty/St/Zip ______________________ ________________ Identification of Source _______ _ ____________________ City/St/Zip Phone#: _____ Fax#: i: Collection Point;__________ ________________________ rCA,CH, Bl? Crieck#: Amount$_ •tf.'

J BACTERIOLOGICAL ANALYSIS Lab#: r*; I g- tab#:_______________ — Heterotrophic Plate Count (hemodialysis & ail others) ORGANIC POTABLE ANALYSIS __ Trihalomethanes (524) ORGANIC NONPOTABLE/SOLID ANALYSIS __ Purgeable Halocarbons (624/8260) ; ‘ 3

_ Volatile Halocarbons (524) , ^ Purgeable Aromatics (624/8260) . W' Sl __ Conform P/A (Public supplies)

f Coliform MPN (priv well, raw, stp) __ Fecal Coliform (all'samples) Microscopic __ Macroscopic _ Volatile Aromatics (524) __ Total Trihaiomethane Potential (510) _ Microextractables (504) Pesticides/PCB screen (508) /Py: At^iplrt & )^onltrite' {8260|, ■ W j Organochlorine Pesticides (808/8081) ^PGB's (Arochlors){608/8081) _HsrbicIdes(SM18/6630,&151) '■ « s 2? ar: __PCS as Decachlorobiphenyl (508A) _ Other Pesticides (SM18/6630) 4_ Petroleum Hydrpcarfaon Scan (310-13) M i £ __ other______________ Refrigerated? yes Chlorinated:? yes no no _ Herbicides (515) _ Pesticides (525) __ Carbamate Pesticides (531) _ Glyphosate (547) __ Glycols b Water ' '^?Acl<i:^«f^ble^-'(^5/827d)' ‘g.. __:5ase Heutral EJttre^blw (825/8270) . ;■>„ | _Diquat (549) □ZGC/MSUnknownScan ,4-j S' FreeChiorine Res:._______ mg/L _ Chlorination Disinfection Byproducts (551) _j'Phthalates (606MS) " -4

Total Chlorine Res:mg/L _Haloacetlc Acids (552) Mi f PH,_____ RADIOCHEMICAL ANALYSIS __Radon ■. ■ _ Other Pestiddes (SMI8/6630) __UCMRList1 _MtBE Only (524) ■>

_ Other._____________ _

INORGANIC ANALYSIS REQUESTED < Lab#: > ■

4_ Color _ Acidfty Aluminum __ .Potassium g __ Turbidity pH __ Alkalinity __ Bromide .^.Antimony /Arsenic *£;^^nlijm'’ Ji'^ilver .yl; 1 r __ Conductivity __ Corrosivity (temp:_____ °C) _ BOD (5 day) __ Bromate/Chiorate/Chiorite _ Chloride __ Cyanide jZ Barium ^Beryllium __ Boron' . . :* . Sodium,. Y :7m: ^■'Thallium £_:Wwcliun’ I | _ Carbonaceous BOD (5 day) _ ; Fluoride « __Cadmium _ Soluble BOD (5 day) _ Hardness, Tofal as CaCOs __ Calcium, as CaCOs . Chemical Oxygen Demand __ Nitrogen, Ammonia as N i __ Dissolved Oxygen __ Nitrogen, Nitrate as N ^-Chromium,Totaf ; ^Volatiles __ Total Organic Carbon _ Nitrogen, Nitrite as N __ Chromium, Hexavalent _Seml-violatties __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N iZCobalt _ Pestlcldes/PCB’s __ Solids, Percant (%) __ Oil and Grease ^^Copper _ Solids, Settleable _ _Phenol wilron :; _ Solids, Suspended __ Phosphorus Total as P ^Lead J' <_TCLF»-Metals _ Solids, Total __ Phosphorus, Ortho as P _ ^.Magnesium g ■ ? _ Solids, Total Dissolved _TCLPTPesticides __ Sulfates jZ Manganese > v: __ TCLP-Herbicides >gblids, Totpl Volatile . __ Surfactants ,4 Mercury • _ TCLP-Volatiles Other _ UV254 _TCLP-BNAs Nickel

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