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

NYC 9/11 Public Portal Document

/‘J AC «■' * YA ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORiM 5v.com WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 4 § •4 X (914)231-1620 Fax (914) 231-1772 i . NYS-ELAP No. 10108 ' Time/Date Set: ’■ FormA-70(rev.10/01)

Sample Type (circle one): 4 ..Potable 3. Non Potable Treated Bottle #'s: 2. Non Potable 4. Other_______________________ Chain of Custody? Yes___ No

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If.' Time/Date Collected: Collected By: Collected From: - A >•{ -X, / ) I D X. Agency Code: Comments: PWS #:_______ Bill to: Source ID: .Type Descriptor

Locatlon’s/lndividual’s Name Name/Company_ Street____________________ Street _____ Clty/St/Zlp______________ __ City/St/Zip Identification of Source Phone#:______ Fax#: 'C'. Collection Ppint_____________ CA,CH, Bl? Check#: Amounts. 4-:,. BACTERIOLOGICAL ANALYSIS Lab#: Lab#:__________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS _ Heterotrophic Plate Count __ Trihalomethanes (524) 8^ (hemodialysis & all others) _ Purgeable Halocart»ns (824/8260) _ Volatile Halocarbons (524) __ Purgeable Aromatics (624/8280) _ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) _ Volatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) . _ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) _ Organochlorine Pesticides (608/8081) S': __ Microscopic __ Microextractables (504) _ PCB’s (Arochlors) (608/8081) __ Macroscopic __ PesticidesZPCB screen (508) _ Herbicides (SMI8/6630,8151) _ API __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SM18/6630) __ Other_________ _ Herbicides (515) __Petroleum Hydrocarbon Scan (310-13) _ Pesticides (525) _ Glycols in Water

I Refrigerated?yes Chlorinated:?yes Free Chlorine Res:__ _ no _no mg/L __ Carbamate Pesticides (531) _ Glyphosate (547) _Diquat (549) __ Chlorination Disinfection Byproducts (551) _ Acid Extractables (825/8270) __ Base Neutral Extractables (625/8270) *zAgc/MS Unknown Scan _ Phthalates (606MS) Total Chlorine Res: __mg/L _Haloacetic Acids (552) __ Other _______ _

{ ® pH __________ RADIOCHEMICAL ANALYSIS __Radon _ Other Pesticides (SMI 8/6630) _UCMRList1 _MtBE Only (524)

Other _

INORGANIC ANALYSIS REQUESTED - Lab#: _ SSidity _ Asidity Aluminum __ Potassium _ Alkalinity Antimony _ Selenium J

I _ pH _ _ Conductivity _ Corrosivity (temp:. _ BOD (5 day) __ Carbonaceous BOD (5 day) .•C) _ Bromide __ Bromate/Chlorate/Chlorite _ Chloride __ Cyanide __ Fluoride _xrArsenic ■ ■Barium .^Beryllium __ Boron __ Cadmium ^.Silver _ Sodium _4/Fhalllum __ Vanadium ^'Zinc __ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOs I. __ Chemical Oxygen Demand _ Dissolved Oxygen __ Nitrogen, Ammonia as N __ Nitrogen, Nitrate as N __ Calcium, Ca*2 .^Chromium, Total CLE _Metals/CN

t __ Total Organic Carbon _ Volatiles __ Nitrogen, Nitrite as N _ Chromium, Hexavalent i_ Total Organic Halides __ Nitrogen, Total Kjeldahl as N _Semi-vioiatiles .^Cobalt _ Pestlddes/PCB's __ Solids, Percent (%) __ Oil and Grease ^Copper _ Solids, Settieable __ Phenol __ Solids, Suspended __ Phosphorus Total as P Lead IfiLE _ Solids, Total __ Phosphorus, Ortho as P _TCLP-Metals __ Magnesium __ Solids, Total Dissolved _TCLP-Pestlcides . __Sulfates Manganese I' _ Solids, Total Volatile __Surfactants .^Mercury _TCLP-Herbicides ’ k."Other _ UV254 Molybdeniffn _TCLP-Volatiles _TCLP-BNA’s _^'Nickel

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