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 & i 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 o US NYS-ELAP No. 10108 Time/Date'Set: Form A-70 (rev. 10/01)

Sample Type (circle one): '.A \ -■ '

Zi. Potable / 3. Non Potable Treated Bottle #’s:

2. Non Potable 4. Other Chain of Custody? Yes___ No Time/Date Collected; Comments: Collected By: 2i_L_ 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 I. 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) (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) __ Pesticides/PCB screen (508) _ Herbicides (SM18/6630,8151) 2__Macroscopic __ API __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SMI8/6630) _ Other:_______________________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) __ 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) I pH _________ __ UCMR List 1 RADIOCHEMICAL ANALYSIS _MtBEOnly (524) ___ Radon __ Other_________ ______________ ) J-J.

I INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Turbidity ___ pH __ Acidity __ Alkalinity __ Bromide Aluminum __ Antimony Arsenic __ Potassium Z Selenium Silver, __ Conductivity __ Bromate/Chlorate/Chlorite ■"* Barium __ Sodiu'm 5. __ Corrosivity (temp:. °C) __ Chloride LL Beryllium _Z Thallium _ BOD (5 day) __ Cyanide __ Boron __ Vanadium Zinc ' I __ Carbonaceous BOD (5 day) _ Soluble BOD (5 day) __ Chemical Oxygen Demand __ Fluoride __ Hardness, Total as CaCOa __ Nitrogen, Ammonia as N __ Cadmium __ Calcium, as CaCOs __ Calcium, Ca+2 CLP _ Metals/CN _ Dissolved Oxygen __ Nitrogen, Nitrate as N __lChromium, Total __ Volatiles Total Organic Carbon __ Nitrogen, Nitrite as N’ __ Chrorhium, Hexavalent __ Sem i-violatiles __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N __ Cobalt __ Pest icides/PCB's __ Solids, Percent (%) __ Oil and Grease Copper __ Solids, Settleable __ Phenol Iron TCLP & ;__ Solids, Suspended' __ Phosphorus Total as P __ Lead _TCLP-Metals _r_ Solids, Total _ Phosphorus, Ortho as P __ Magnesium Vr __ TCLF^-Pesticides _ Solids, Total Dissolved , __ Sulfates __ j Manganese __ TCLPj-Herbicides __ Solids, Total Volatile __ Surfactants __ Mercury __ TCLP-Volatiles _Z Other: »______________ _ -UV254 _1 Molybdenum _ TCLF-BNA's Nickel

1 I NYC-WTC_000074671