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 (914)231-1620 Fax (914) 231-1772 Zi 1 8 NYS-ELAPNo. 10108 Time/Date Set: Form A-70 (rev. 10/01)

Sample Type (circle one); 7 ■'7 7/" / (.1. Potable 3. Non Potable Treated Bottle #’s:

2. Non Potable 4. Other Chain of Custody?___ Yes____ No ''^ime/Date Collected: Comments:

Collected By: Agency Code: PWS #:_______ Source ID; Type Descriptor:

Collected From: Bill to;

Location’s/lndividual’s Name Name/Company

’ Street______ _____________ Street_________ City/St/Zip________________ City/St/Zip

Identification of Source Phone#: Fax#:

Collection Point__________ ; 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) I' " ' (hemodialysis & all others) __ Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) __ Volatile Aromatics (524) __ Acrolein & Acrylonitrile . (8260) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081) __ Fecal Coliform (all samples) k __ Microscopic __ Microe'xtractables (504) _ PCB’s (Arochlors) (608/8081) I. __ Pesticides/PCB screen (508) __ Herbicides (SM1'8/6630,8151) __ Macroscopic __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides^ (SMI8/6630) _ API __ Herbicides (515) __ Petroleum Hydrocarboni Scan (310-13) __ Other:_______________________ __ Pesticides (525) __ Glycols in Water ?■ Refrigerated?yes___ no __ Carbamate Pesticides (531) _ Acid Extractables (625/8270) __ Glyphosate (547) __ Base' Neutral Extractables (625/8270) Chlorinated:? yes___ no __ Diquat (549) ^'GC/MS Unknown Scan Tree Chlorine Res:mg/L __ Chlorination Disinfection Byproducts (551) __ Phthalates (606MS) I

Total Chlorine Res:mg/L __ Haloacetic Acids (552) __ Other;____________ __ Other Pesticides (SMI8/6630) pH _____________ _UCMRList 1 RADIOCHEMICAL ANALYSIS _ MtBE Only (524) ___ Radon

E ___ Other______________________

INORGANIC ANALYSIS REQUESTED - Lab#: ‘__ Color __ Turbidity pH __ Acidity __ Alkalinity __ Bromide “'Aluminum ‘•'Antimony JiArsenic __ Potassium _i; Selenium ^^'Silver j

__ Conductivity __ Bromate/Chlorate/Chlorite Ji. Barium __ Sodium __ Corrosivity (temp;. “C) __ Chloride Beryllium Li'Thallium Si BOD (5 day) __ Cyanide __ Boron < __ Vanadium r' __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium _iL.'''Zinc ' _ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOs CLP __ Chemical Oxygen Demand __ .Nitrogen, Ammonia as N __ Calcium, Ca*2 i-’ __ Metals/CN __ Dissolved Oxygen __ Nitrogen, Nitrate as N v_Chromium, Total __ Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Semi-violatiles, __ Total Organic Halides _ Nitrogen, Total Kjeldahl as N .kCobalt __ Pesticides/PCB’s __ Solids, Percent (%) __ Oil and Grease ‘'Copper ■ I __ Solids, Settleable __ Phenol Iron tclp __ Solids, Suspended __ Phosphorus Total as P V'Lead _TCLP-Metals __ Solids, Total Phosphorus, Ortho as P __ Magnesium __ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates Manganese I’*' __ TCLP-Herbicides __ ^Solids, Total Volatile __ Surfactants __ Mercury _ TCLP-Volatiles Other: ___________ __ UV254 Molybdenum _ TCLP-BNA’s Nickel

NYC-WTC_000b74668