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

NYC 9/11 Public Portal Document

I: ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM

I. WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (9ri4) 231-1620 Fax (914) 231-1772 ....ri

I;r; Time/Date Set:

Sample Type (circle one); potable 3. Non Potable Treated Bottle #’s: NYS-El^ No. 10108 -Ferm A-70(rev. 10/01)

Is 2. Non Potable 4. Other. Chain of Custody? Yes No TlmeflDate Collected: ’■ ■/ Comments: ■ Collect By: Agency Code: __L_ PWS#:.^______ Source ID: .Type Descriptor: Collected From: Bill to: Location’s/lndlvldual's Name __________ ■ Name/Company _ ‘ Street _ ______ __________________________ Street______ __ Clty/St/Zlp ___________ _____________________________ City/St/ZIp Identification of Source _____________________ ______ Phone#: _____ ^.Collection Point •' ____________ __________ |CA,CH, Bl? Check#:

I' BACTERIOLOGICAL ANALYSIS Lab#:_ Lab#:a___________ s ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOUD ANALYSIS _ Heterotrophic Plate Count _Trihaldmethane8 (524) _ Purgeable Halocarbons (624/8260) J (h^odiaiysis Sall others) _ Volatile Halocarbons (524) _ Purgeabie Aromatics {624/8260) ^ CoBfcto P/A. (Public supplies) Ot^ift^ MPN (prlv well, raw, stp) _ Volatile Aromatics (524) i_ Fecal CollforiTi (alt samples) _ Total Trihalomethane Potential (510) _ Organochlorine Pesticldes (608/8081) lY, Microscopic _ Mlcroextractables (504) _ pea’s (Arochior8) (608/8081) _Pesticldes/PCB screen (508) _ Herbicides (SM18/6630,8151) I i. Ntet^oscoplc _ PCB as Decachlorobiphenyl (508A) Other PesticIdes (SMl8/6630) , 3 _ Herbicides (515) _ Petroleum Hydrocarbon Scan (310-13) > —— _Pestiddes (525) Refrigerated? yes no __ Carbamate Pesticides (531) _Acld Exti%^leS(62S/8270) 1 Chlorinated:?. yes no _ Glyphosate (547) _ Diquat (549) st’' Free Chlorine Res:____ mg/L _ Chlorination Disinfection Byproducts (551) _ Phthalate, (wfeilS) ^I Chlorine Res:mg/L _Haloacetic Adds (552) - Other----- -------------------- ------- -------- .A

fc ^J^I^HEMICAL ANALYSIS M_Ftedon _Other Pesticides (SMI8/6630) _UCMRList1 _MtBE Only (524) 1 Bl

i^'- .other £a=±======d=============^ —M----- - INORGANIC analysis REQUESTED - Lab#: '_ Color _ Acidity aw J^^Aluminum -t;: __ Potassium % ;1

Yu Turbidity _AlkaHnlty Antimony .^.iS^ler&i WPH ■ _Conductivity _ Bromide __ Bromate/Chlorate/Chlorite ^^Arsenlc ' ^^Batiura 'rC' • I : < ..-a 1 i__Sodiumpvv\r. .'Y ' _ Corroslvlty (temp:____ "C) _Chioride.,W^’ i^Beryllium / _i_: Thallium • .a BOD (5 W" ^Cy^nid^iWC' Borah 2i.Ai^hadI«m _ Carbonaceous BOD (5 day) _ Fluoride __ Cadmium ;^nc'\, Soluble BOD (5 day) _ Hardness. Total as CaCOs _iC9l^nm. as CaCOa .4 Ohernktel Ox^en Demand _ Nitrogen, Ammonia as N ^Cafelum.Ca« __ Dissolved Oxygen _ Nitrogen, Nitrate as N udChromlum, Total _ Total Organic Carbon _ Nitrogen, Nitrite as N _ Chromium, Hexavalent _^mi^dlatiie8 _ Total Organic Halides _ Nitrogen, Total Kjeldahl as N ^Cobalt _Pesticides/PCB’s Solids, Percent (%) __ Oli and Grease - ..^Copper Li WterSettieable 4 _ Phenol ir-lron S' _ Solids. Suspended _ Phosphorus Total as P j<Lead _ Solids, Total __ Phosphorus, Ortho as P ___ Magnesium \_TCLP-W1S _TCLP-Pestlcides Solids, Total Dissolved _ Sulfates ii; Manganese _,,Sond8.T(?tetVblatile .^Mercury i._*TCLP-HerbicWes P' __ Surfactents - ■. «< ’ _ TCLP-Voiatiles J .a Other: _i2_i__________ _ UV254 j__ Moiyixtoum _TCLP-BNA’s /. ^Nickel

NYC-WTC_000074580