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 1 a*.-*

2 Dana Road, Valhalla, New York 10595 <1 X (914) 231-1620 Fax (914) 231-1772 ,f^YS-ELAP No. 10108— Time/Date Set: ' Form A-70 (rev. 10/01)

I Sample Type (circle one): t- H.^Potabie 3. Non Potable Treated Bottle #’s: . ■ X'

2. Non Potable 4. Other_____________________ Chain of Custody? Yes No f TimeAJate Collected: Comments: Collected By: Agency Code: PWS#:_______ Source ID: .Type Descriptor: Collected From: Bill to: Location’s/lndividuars Name Name/Company _ Street________________ Street________ Clty/St/ZIp_____________ City/St/Zip I: Identification of Source Phone#:______ Fax#: Collection Point T I CA.CH,B1? Check#: Amounts.

Lab#: i; BACTERIOLOGICAL ANALYSIS Lab#:.___________ _________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count _Trihalomethanes (524) _ Purgeable Halocarbohs (824/8260) I' (hemodialysis & all others) _ Coliform P/A (Public supplies) _ Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) ;_ ; Coliform MPN (prtv well, raw, stp) __ Volatile Aromatics (524) _ Acroleins Acrylonitrile (8280) ;__Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) __ Orgahochlorine Pesticides (608/8081) _ Microscopic __ Microextractables (504) _ PCB’s (Arochlors) (608/8081) __ Macroscopic __ Pestlcldes/PCB screen (508) _ Herbicides (SM18/863O,8151) API __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SM18/6630) a, __ Other:_________ _ Herbicides (515) _ Petroleum Hydrocarbon Scan (310-13)

Ir Refrigerated?yes Chlorinated:?yes Free Chlorine Res: no no .mg/L _ Pesticides (525) __ Carbamate Pesticides (531) _ Glyphosate (547) _ Diquat (549) __ Chlorination Disinfection Byproducts (551) _ Glycols in Water _ Acid Extractables (625/8270) _ Base Neutral Extractables (825/8270) _i/Gc/MS Unknown Scan _ Phthalates (806MS) /?

I Total Chlorine Res:

k: • pH__________ .mg/L _Haloacetic Acids (552) _ Other Pesticides (SM18/6630) _UCMRList1 _MtBE Only (524) ■ — Other: ■ v , -

RADIOCHEMICAL ANALYSIS _Radon OthQr__________________

INORGANIC ANALYSIS REQUESTED - Lab#: __

f __ Color _ Turbidity _ Acidity __ Alkalinity v' Aluminum Antimony __ Potassium Ji. Selenium

I _ pH _ Conductivity __ Corrosivity (temp:. “C) __ Bromide __ Bromate/Chlorate/Chlorite _ Chloride Arsenic Barium _^Beryllium .^Silver __ Sodium j,YThalIium I. _ BOD (5 day) __ Carbonaceous BOD (5 day) _ Cyanide __ Fluoride __ Boron _ Cadmium _ : Vanadium l ‘Zinc _ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOs _ Chemical Oxygen Demand __ Nitrogen, Ammonia as N _ Calcium, Ca«

1 __ Dissolved Oxygen __ Total Organic Carbon __ Total Organic Halides _ Solids. Percent (%) __ Nitrogen, Nitrate as N __ Nitrogen, Nitrite as N __ Nitrogen, Total Kjeldahl as N _4.Chromlum, Total __ Chromium, Hexavalent _Cobalt _Metals/CN _ Volatiles _Semi-violatiles _ PestIcides/PCB’s _ Oil and Grease __ Copper __ Solids, Settleable __ Phenol _Iron __ Solids, Suspended __ Phosphorus Total as P __ Lead ISLE _ _ Solids, Total __ Phosphorus, Ortho as P __TCLP-Metals __ Magnesium _TCLP-Pestlcldes __ Solids, Total Dissolved _ Sulfetes Manganese _TCLP-Herbicides __ Solids, Total Volatile __ Surfectants □^Mercury ( _ . Other: ..../ .y________ _ TCLP-Volatiles _ UV254 _ Molybdenum _ TCLP-BNA’s Nickel

NYC-WTC_000074604