Chain of custody form, NYC DEP sample AE05050, Mar 2002

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ’7^ WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 A o/ ■ I < '.Ji—i (914)231-1620 Fax (914) 231-1772 t NYS-ELAP No. 10108 Time/Date Set: Form A-70 (rev. 10/01)

Sample Type (circle one): p. Potable 3. Non Potable Treated Bottle #'s: 2. Non Potable 4. Other____________ Chain of Custody?___ Yes___ No Time/Date Collected; t " ./>• Comments: Collected By: -Y t I/' Agency Code: PWS #:;______ Source ID: Type Descriptor: I Collected From; Bill to: .•Location's/lndividuars Name Name/Company Street_________________ Street________ City/SVZip______________ City/St/Zip , Identification of Source Phone#: Fax#: J. -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) (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) ‘__ 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 (SMI 8/6630,8151) _ API __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SMI8/6630) __ Other:_____________________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) 3; __ Pesticides (525) __ Glycols in Water 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) Total Chlorine Res:mg/L __ Haloacetic Acids (552) __ Other:____________________________ __ Other Pesticides (SMI8/6630) pH ___________ ■ _UCMRList1 RADIOCHEMICAL ANALYSIS _MtBEOnly (524) r-i!: ^_Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ /'cidity i’/ Aluminum __ Potassium

I' ;_ Turbidity _ pH __ Conductivity __ Alkalinity __ Bromide __ Bromate/Chlorate/Chlorite . Antimony v Arsenic Barium __ Selenium __ Silver. __ Sodium __ Corrosivity (temp; °C) __ Chloride u Beryllium __ Thallium _ BOD (5 day) __ Cyanide __ Boron __ Vanadium •__ Carbonaceous BOD (5 day) __ Fluoride , __ Cadmium '__ Zinc

I _ Soluble BOD (5 day) __ Chemical Oxygen Demand __ Dissolved Oxygen __ Hardness, Total as CaCOs __ Nitrogen, Ammonia as N __ Nitrogen, Nitrate as N __ Calcium, as CaCOa __ Calcium, Ca*2 __ Chromium, Total CLP i _ Metals/CN __ Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Semi-violatiles __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N Cobalt __ Pesticides/PCB’s __ Solids, Percent (%) __ Oil and Grease '■ __ Copper __ Solids, Settleable __ Phenol __ Iron TCLP __ Solids, Suspended __ Phosphorus Total as P _ Lead _TCLP-Metals \__ Solids, Total __ Phosphorus, Ortho as P ___Magnesium __ TCLP-Pesticides ‘Y_ Solids, Total Dissolved __ Sulfates __ Manganese __ TCLP-Herbicides \ Solids, Total Volatile __ Surfactants __ Mercury _ TCLP-Volatiles k Other:_________________ _ UV254 __ Molybdenum _ TCLP-BNA’s _ Nickel

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