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

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM’ nil WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 o (914) 231-1820 Fax (914) 231-1772 NYS-e^PNo. 10108'" V Tme/Date Set: Fo^A-70 (rev. 10/01)

S^pIeType (circle one): I-&- (^1, Potable 3. Non Potable Treated -

i 2. Non Potable Time/Date Collected: 4. Other___________ Chain of Custody?Yes No Comments: Collected By:.5"^ aA Agency Code: PWS #: ___ Source ID: .Type Descriptor Collected From: Bill to: Location's/lndividual’s Name /X. Name/Company Street.:_______________ Street _____ CIty/St/Zip_________ ___ City/St/Zip Identification of Source Phone#: ____ — Fax#:.

I Collection Point 3 I r* CA,CH, Bi? Checl^ Amounts.

r. BACTERIOLOGICAL ANALYSIS Lab#:

JI Lab#:_____________________ ORGANIC POTABLE ANALYSIS ORGANIC NQNPOTABLE/SOLID ANALYSIS Heterotrophic Plate Count __ Trihalomethanes (524) _ Purgeablo Halocarbons (624/8260) (hemodlal^s & all others) __ Coliform P/A (Public supplies) _ Volatile Halocarbons (524) _ Purgeable Aromatics (624/8260) _ _Coliform MPN (priv well, raw. stp) __ Volatile Aromatics (524) _ Acrolein & Acrylonitrile (8260) _ _Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) _ Organochlorine Pesticides (608/8081) __ Microextractables (504) __ PCB’s (Arbchlore) (608/8081) __ Microscopic _ Herbicides^ (SM18/6630,8151) __ Macroscopic __ Pestiddes/PCB screen (508) — API __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SM18/6630) _ Other__________________ _ Herbicides (515) _ PetroleumI Hydrocarbon Scan (310-13) _ Pesticides (525) Glycols in Water Refrigerated?yes no __ Carbamate Pesticides (531) _ Acid Extralotables (625/8270) I'' Chlorinated:?yes no __ Glyphosate (547) _Diquat (549) _/Base Neutral Extractabtes (625/8270) .if GC/MS Unknown Scan Free Chlorine Res:_______ mg/L __ Chlorination Disinfection Byproducts (551) _ Phthalates! (8Q6MS) Total Chlorine Res:mg/L __ Haioacetic Adds (552) : Other _Other Pestiddes (SM18/6630) _UCMRUst1 RADIOCHEMICAL ANALYSIS _MtBE Only (524) _Radon _Other ____________

INORGANIC ANALYSIS REQUESTED - tab#: _ ........ — - _ Color __ Acidity _^^uminum __ Potassium __ Turbidity _ Alkalinity _^fAntimony __:Selenium — pH __ Bromide Arsenic _i^llver __ Conductivity __ Bromate/Chiorate/Chlorite j£jBarium __ Sodium .... __ Corrosivity (temp:, .“C) _ Chloride Beryllium _&^ThalIium _ BOD (5 day) __ Cyanide _ Boron _ Vanadium _ Carbonaceous BOD (5 day) _ Fluoride __Cadmium L/Zinc7 _ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOs __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*2 __ Dissolved Oxygen __ Nitrogen, Nitrate as N ir^hromium. Total _Metals/CN _ VolatHes -//Total Organic Carbon __ Nitrogen, Nitrite as N __ CJjromium, Hexavalent __ Semi-vlolatlles "- Total Organic Halides __ Nitrogen, Total Kjeldahl as N jrC^balt _ Pesticides/PCB's _ Solids, Percent (%) __ OH and Grease -T^tJopper __ Solids, Settleable __ Phenol _rrron TCLP __ Solids, Suspended __ Phosphorus Total as P _irLead _TCLP-Metals _ Solids, Total __ Phosphorus, Ortho as P ■Magnesium _TCLP-Pestiddes __ Solids, Total Dissolved __ Sulfates Manganese _TCLP-Herblddes _ Solids, Total Volatile __ Surfactants ‘^Mercury _TCLP-Volatiles JL-dther __________ _ UV254 Molybdenum __TCLP-BNAs jZ Nickel

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