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

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 NY>€LAPNb. 10108 * Time/Date Set- EdrmA-70 (rev. 10/01)

SampleType (circle one): /Ootable 3. Non Potable Treated Bottle #*8: S^Non Potable 4. Other . ______ Chain of Custody? Yes No Time/Date Collected: _ Comments: Collected By: Bt,r fC t./g Agency Code: ------------ Source ID; Type Descriptor Collected From: ' Bill to: Location's/lndividuai’s Name Name/Company Street_____ _________ _ Street________ City/St/Zip_____________ Clty/St/Zip Identification of Source Phone#:______ Fax#: Collection Point, I CA,CH,BI? Check#: Amount$_

4 BACTERIOLOGICAL ANALYSIS Lab#: Lab#:_____________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS _ Heterotrophic Plate Count __ Trihalomethanes (524) I (hemodial^s & all others) __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw. stp) _ Volatile Halocarbons (524) _ Volatile Aromatics (524) __ Total Trihalomethane Potential (510) _ Purgeable Halocarbons (624/8260) _ Purgeable Arorhatics (824/8260) _ Acrolein & Acrylonitrile (8260) _ Organochiorine Pesticides (608/8081) __ Fecal Coliform (all samples) __ Microscopic _ Microextractables (504) _ PCB’s (Arochlors) (60W8081) __ Macroscopic _ Pesticides/PCB screen (508) Herbicides (SM18/6630,8151) i _ API __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SM18/6830) __ Other _ ________ _ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13)

I Refrigerated?yes no _ Pesticides (525) __ Carbamate Pesticides (531) _ Glyphosate (547) _ Gtycols inVfeter - A _ Acid Extractables (625/8270) _^se Neutral Extractables (625/8270)

II'. Chlorinated:?yes no _Diquat (549) Ji^C/MS Unknown Scan J Free Chlorine Res:___ . mg/L __ Chlorination Disinfection Byproducts (551) _ Phthalates (606MS) Total Chlorine Res: .mg/L _Haioacetic Acids (552) _ Other _________ ■ _ Other Pesticides (SM18/6630) pH __ ___ ___ _ _UCMRUst1 RADIOCHEMICAL ANALYSIS _MtBE Only (524) _Radori Y/ 4 Other______________

r INORGANIC ANALYSIS REQUESTED - Lab#; _ _ Color _ Turbidity _ Acidity __ Alkalinity luminum mony _ Potassium Y^lenium 13 _PH __ Bromide mic Silver __ Conductivity __ Bromate/Chlorate/Chlorite turn ^^dlum r• ■ ■ __ Corrosivity (temp;. °C) __ Chloride yilium i>*TTiallium

I BOD (5 day) _ _Cyanide _jBoron adium _ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium _ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOs __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N _Cateitjm, Ca« CLE __Dissolved Oxygen __ Nitrogen, Nitrate as N _»^Vhromlum, Total _Metal8/CN __ Total Organic Carbon __ Nitrogen, Nitrite as N _ Volatiles Ci^romium, Hexavalent __ Seml-violatlles

i __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N _^;^balt _ Solids. Percent (%) __ Oil and Grease _ Pestlcldes/PCB’s _ Solids, Settleable ___Phenol _riron .ji^ead TCLP __ Solids, Suspended __ Phosphorus Total as P _ Solids, Total __ Phosphorus, Ortho as P inesium _TCLP-Metals _ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates ..i^onese _^id8. Total Volatile _TCLP-Herbicides __ Surfactants ircury _TCLP-Volatiles other: „ LIV254 _TCLP-BNAS

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NYC-WTC_000074600