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

NYC 9/11 Public Portal Document

liS ACeo^.: • 1'1 ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ' WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road. Valhalla, New York 10595

I Time/Date Set: (914)231-1620 Fax (914) 231-1772 IYS-ELAPNo. 10108 ’orm A-70 (rev.10/01) i ■ Sample Type (circle one): 4.Potable,’ 3. Non Potable Treated Bottle #’s: 2. Non Potable 4. Other Chain of Custody? Yes No F Tlme/Date Collected: Collected By: __ ________ Agency Code: Comments: PWS#:_______ Source ID: .Type Descriptor Collected From: Bill to: Location’s/lndlvidual's Name Name/Company _

rfc Street________________ ' Clty/St/Zip_____________ Street_______ _ City/St/Zip____ 1 Identification of Source Phone#:______ Fax#: iS' Collection Point________1 I' fl. [ CA.CH. Bl? Check#: Amounts

■■ BACTERIOLOGICAL ANALYSIS Lab#: Lab#: iXV. ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLEZSOLID ANALYSIS _ Heterotrophic Plate Count __ Trihalomethanes (524) fc” (hemodialy^s & all others) _Volafile Halocarbons (524) __ Purgeable Halocarbons (824/8260) _ Purgeable Aromatics (624/8260) Coliform P/A (Public supplies) e Coliform MPN (prlv well, raw, stp) _ Fecal Coliform (all samples) _ Volatile Aromatics (524) _ Total Trihalomethane Potential (510) _ Acrolein a Acrylonitrile (8260) _ Organochlorine Pesticides . (608/8081) 5

__ Microscopic __ Microextractables (504) _ PCB’s (Arochlors) (608/8081) __ Pesticides/PCB screen (508) _ Herbicides (SM18/6630,8151) I': _ Macroscopic __ API __ PCB as Decachlorobiphenyl (508A) , ( _ Other Pesticides (SM18/6830)

I"S- ^Oth^------- ----------------------- Refrigerated?yes Chlorinated:?yes no no _ Herbicides (515) _ Pesticides (525) __ Carbamate Pesticides (531) _ Glyphosate (547) __ Petroleum Hydrocarbon Scan (310-13) _ Glycols in Water _ Add Extractables (625/8270) -

_ Base Neutral Extractables (625/8270) _Diquat (549) •±SGC/MS Unknown Scan

r Free Chlorine Res:___ Total Chlorine Res: pH _ ________ .mg/L mg/L __ Chlorination Disinfection Byproducts (551) _Haloacetlc Acids (552) _ Other Pesticides (SM18/6630) _UCMRList1 _ Phthalates (6O6MS) _ Other_____,__^____.

i RADIOCHEMICAL ANALYSIS _MtBE Only (524) ■I

___Radon _ Other__________________

INORGANIC ANALYSIS REQUESTED - Lab#: Color _ Aridity _.:fAluminum __ Potassium _ Turbidity _ Alkalinity Antimony ^Selenium - _ pH __ Bromide _L.Arsenic ^Silver _ Conductivity __ Bromate/Chlorate/Chlorite __ Barium _ _Corrosivity (temp:. .’C) _ Chloride _ Beryllium Thallium __ BOD (5 day) __ Cyanide __ Boron __ Vanadium _ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium Zinc __ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOs I- _ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca+^ we _M8tals/CN I __ Dissolved Oxygen __ Total Organic Carbon __ Total Organic Halides __ Nitrogen, Nitrate as N __ Nitrogen, Nitrite as N __ Nitrogen, Total l^eldahl as N __ Chromium, Total __ Chromium, Hexavalent _Cobalt _i_ Vblatlles __ Seml-violatiles _ Solids, Percent (%) __ Oil and Grease _ Copper __ Pestiddes/PCB’s _ Solids, Settleable __ Phenol _ Iron __ Solids, Suspended ICLE I. _ Solids, Total __ Phosphorus Total as P __ Phosphorus, Ortho as P _L8ad __ Magnesium _TCLP-Metals __TCLP-P8sticldes __ Solids, Total Dissolved __ Sulfates _2 Manganese _TCLP-Herbicides _ Solids, Total VolaWs __ Surfactants Mercury __'^Other _ UV254 _ Molybdenum _TCLP-Voiatiles _TCLP-BNA’s _ Nickel . jit

NYC-WTC_000074602