Chain of custody form, NYC DEP sample AE04941, Mar 2002

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM 1 WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 NY^^ELAP No.10108—• Time/Date Set: Form A-70 (rev.10/01)

Sample Type (circle one): 5 5 — ^%otable 3. Non Potable Treated Bottle#'s: J W. W W: 2. Non Potable 4. Other Chain of Custody? Yes No Time/Date Collected; Comments: JUn--------------------------- Collected By; Agency dode: PWS #: Source ID: -.Type, Descriptor: Collected From: Bill to: Location’s/lndivlduars Name Name/Company _ *» street____________________ Street________ City/St/Zip________________ Clty/St/Zlp Identification of Source Phone#:_______ Fax#: Collection Point _ [ CA.CH. Bl? Check#: Amounts.

F f- BACTERIOLOGICAL ANALYSIS Lab#:._____________________ Lab#: ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS _ Heterotrophic Plate Count __ Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) (hemodialysis & ail others) __ Coliform P/A (Public supplies) _ Volatile Halocarbons (524) _ Purgeable Aromatics (624/8260) __ Coliform MPN (prlv well, raw, stp) _ Volatile Aromatics (524) _ Acrolein & Acrylonitrile (8260) __ Fecal Coliform (ali samples) __ Total Trihaiomethane Potential (510) __ Organochlorine Pesticides (608/8081) __ Microextractables (504) _ PCB’6 (Arochlors) (608/8081)

I. _ Microscopic Macroscopic _ Pesticldes/PCB screen (508) _ Herbicides (SM18/6630,8151) __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SM18/6630) — API _ Herbicides (515) _ Petroleum Hydrocarbort Scan (310-13) 1 _Other: _ Pesticides (525) Glycols in Water Refrigerated?yes no __ Carbamate Pesticides (531) .'■Al Add Extradtables (625/8270)^.,

I Chlorinated:?yes no Free Chlorine Res:mg/L __ Glyphosate (547) _ Diquat (549) __ Chlorination Disinfection Byproducts (551) , „^8e Neutral Extractables (625/8270) ■^GC/MS Unknown Scan < ._ Phthalates (606MS) Total Chlorine Res:mg/L _Haloacetic Acids (552) Other: .1

f pH _ Other Pesticides (SM18/6630) * _UCMRList1 RADIOCHEMICAL ANALYSIS _MtBE Only (524) ft _Radon __ Other__________________

B' INORGANIC ANALYSIS REQUESTED - Lab#: _ __ Color _ Acidity Aluminum __ Potassium __ Turbidity _ Alkalinity Z Antimony ^Y'Selenium ^Arsenic I •— pH _ Conductivity __ Corrosivity (temp:. _ BOD (5 day) °C) __ Bromide __ Bromate/Chlorate/Chlorite _ Chloride __ Cyanide j^Barium jZ'Beryllium __ Boron ^Silver __ Sodium .i/Thallium ' __ Vanadium Carbonaceous BOD (5 day) __ Fluoride __ Cadmium je^Zinc _ Soluble BOD (5 day) __ Hardness, To^as CaCOs __ Calcium, as CaCOs _ Chemical Oxygen Demand __ Nitrogen, Arnr^rta as N __ Calcium, Ca*’ sEe” _ _ Dissolved Oxygen __ Nitrogen, Nitrate'!^ ^.'Chromium, Total __Metals/CN __ Total Organic Carbon _ Nitrogen, Nitrite asN Volatiles __ Chromium, Hexavalent 1/ __ Total Organic Halides ' Nitrogen, Total Kjeldahl as N .^Cobalt _Semi-violatlles

t' _ Solids, Percent (%) _ Pesticides/PCB's

rI ’ Oil and Grease zjCopper __ Solids, Settleable z Iron TCLP _ Solids, Suspended Total as P Y^Lead _TCLP-Metais __ Solids, Total _ Solids, Total Dissolved __ Solids, Total Volatile -^5 __ Surfactants Magnesium ^Manganese ^Mercury __TCLP-P8sticides _TCLP-Herbicides I' Z. Other. ___________ _ UV254 iC Molybdenum Nickel _TCLP-Volatile8 _TCLP-8NA’s

I, NYC-WTC_000074599