Chain of custody form, NYC DEP sample AE05050, 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 O /■ I A U/ ■ I (914)231-1620 Fax (914) 231-1772 IS iw Time/Date Set; s s NYS-ELAP No. 10108 Form A-70 (rev. 10/01)

Sample Type (circle one): I. " 6 Bottle #’s: I 1. Potable 3. Non Potable Treated '“2.'Non Potable 4. Other a ■ Chain of Custody? Yes No i- Time/Date Collected: V* <1 “ I Comments: Collected By: 1 ■ - VA i) ! Agency Code: PWS #;_________ Source ID: Type Descriptor:

t Collected From: Bill to; Location’s/lndividual’s Name OG-i so Name/Company { Street_____________________________ Street ________ ' City/St/Zip_________________________ City/St/Zip Identification of Source Phone#:________ Fax#: L Collection Point__ iiKvn CA,CH, Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:__________________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count __ Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) (hemodialysis & all others) __ Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) _ Coliform P/A (Public supplies) ' __ Acrolein' & Acrylonitrile (8260) __ Coliform MPN (priv well, raw, stp) __ Volatile Aromatics (524) __ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081) .__ Microscopic __ Microextractables (504) __ PCB’s (Arochlors) (608/8081) __ Macroscopic __ Pesticides/PCB 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 1 Refrigerated?yes no __ Carbamate Pesticides (531) _ Acid Extractables (625/8270) Chlorinated:? yes no __ Glyphosate (547) __ Base Neutral Extractables (625/8270) __ Diquat (549) ■••.^^GC/MS Unknown Scan ' Free Chlorine Res: mg/L __ Chlorination Disinfection Byproducts (551) _ Phthalates (606MS) J- Total Chlorine Res: - rng/L __ Haloacetic Acids (552) __ Other:______________________________ __ Other Pesticides (SMI 8/6630) pH _____________ _UCMR List 1 RADIOCHEMICAL ANALYSIS __ MtBE Only (524) L' ___ Radon _ _ Other_________ _____________

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Acidity \_XAruminum __ Potassium __ Turbidity __ Alkalinity I '.^'‘Antimony Ji'Selenium _ pH __ Bromide X'Arsenic jiLf^ilver __ Conductivity __ Bromate/Chlorate/Chlorite Barium __ Sodium -__ Corrosivity (temp:. “C) __ Chloride Beryllium Thallium _ BOD (5 day) __ Cyanide __ Boron j __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Vanadium __ >Zinc t «__ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOs ■ Chemical Oxygen Demand CLP __ Nitrogen, Ammonia as N __ Calcium, Ca+2 _Metals/CN __ Dissolved Oxygen __ Nitrogen, Nitrate as N 'vxfchromium. Total __ Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Semi-violatiles __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N 2_.Cobait _ Pesticides/PCB’s __ Solids, Percent (%) __ Oil and Grease ' ^Copper .! __ Solids, Settleable __ Phenol /Iron 1 TCLP __ Solids, Suspended __ Phosphorus Total as P _'L'ead _TCLP-Metals - Solids, Total __ Phosphorus, Ortho as P __ Magnesium __ TCLF’-Pesticides __ Solids, Total Dissolved __ Sulfates ..'•Manganese __ TCLP-Herbicides __ Solids, Total Volatile __ Surfactants • -Mercury _ TCLP-Volatiles Other; . v _ UV254 Molybdenum _ TCLP-BNAs I __ Nickel

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