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

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM JA^stcliester WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914) 593-5575 NYS-ELAPNo. 10108 Time/Date Set: Form A-70 (rev. 1/96)

Sample Type (circle one); (4. Potable. 3. Non Potable Treated Bottle #’s: \ .1

2. Non Potable 4. Other Chain of Custody?___ yes___ no Time/Date Collected: 1 Comments; Collected By; 4 ! 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-O CA,CH, Bl? Check#: . Amounts

BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS F

Lab#:______________________ Lab#:________________________ (circle tests) (circle tests) 1. Heterotrophic Plate 1. Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260) Count (hemodialysis & all others) 2. Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260) 2. Coliform P/A (public supplies) ■ 3. Volatile Aromatics (524) 3. Acrolein & Acrylonitrile'(624) 3. Coliform MPN (priv well, raw, stp) 4. Total Trihalomefhane Potential (510) 4. Phthalates (625/8270) 4. Fecal Coliform (all samples) 5, Microextractables (504) 5. Organochlorine Pesticides (608/8081) 5. Microscopic 6. Pesticides (507) 6. PCB’s (Arochlors) (608/8081) 6. Macroscopic 7. Pesticides/PCB screen (508) 7. Methoprene (616) ' 7. API 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPAI 978/8151) 8. Other:____________________ 9. Herbicides (515) 9. Pesticides (SMI 8/6630) 10. Pesticides (525) 10. Petroleum Hydrocarbon Scan-(310-13) Refrigerated?yes___ no 11. Carbamate Pesticides (531) 11. Glycols Chlorinated:? yes no 12. Glyphosate (547) 12. Acid Extractables (625/8270) 13. Diquat (549) 13. Base Neutral Extractables (625/8270) Free Chlorine Res:. mg/L 14. Chlorination Disinfection Byproducts (551) 14. GC/MS Semivolatile Unknown Scan 15. Haloacetic Acids (552) 15. Purgeable Halocarbons (DEF) Total Chlorine Res: mg/L 16. Pesticides (SIVI18/6630) 16. Purgeable Aromatics (DEF) pH 17. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB’s (DEF) 18. Other:_______ __________________ 18. Other;__________________________

INORGANIC ANALYSIS REQUESTED - Lab#; (circle tests) 1. Color 20. Acidity ( 39. Aluminum 59. Potassium r 2. Turbidity 21. Alkalinity, as CaCOs 40. Antimony _60. Selenium 3. pH 22. Bromide 41. Arsenic ”6T. Silver 4. Conductivity 23. Bromafe/Chlorate/Chlorite 42. Barium 62. Sodium 5. Corrosivity (temp:. ®C) 24. Chloride 43. Beryllium - 63. Thallium I 6.' BOD (5'day) 25. Cyanide 26. Fluoride 44. Boron 45. Cadmium ”64. Vanadium 65. Zinc 7. Soluble BOD (5 day) 8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOs 46. Calcium, as CaCOa "CLP 9. Chemical Oxygen Demand 28. Nitrogen, Ammonia as N 47. Calcium, Ca*^ 66. Metals/CN TO. Dissolved Oxygen 29. Nitrogen, Nitrate as N 48. Chromium, Total 67. Volatiles ' ■1 11.' Total Organic Carbon 30. Nitrogen, Nitrite as N ' 49. Chromium, Hexavalent 68. Semi -violatiles

t 12. Total Organic Halides 13. Solids, Percent (%) 14. Solids, Settleable 15. Solids, Suspended 16. Solids, Total 31. Nitrogen, Total Kjeldahl as N 32. 33. Oil an Phenol Grease

34. Phosphorus Total as P 35. Phosphorus, Ortho as P 50. Cobalt 51. Copper 52. Iron 53.Lead 54 Magnesium 69.Pesticides/PCB’s 70. Disk} Deliverables TCLP 71 TCLP-Metals 72.TCLP-Pesticides 17; Solids, Total Dissolved 36. Sulfates 55 Manganese 73. TCLP-Herbicides 18. Solids, Total Volatile 37. Surfactants 56. Mercury 74. TCLP-’Volatiles .^19. Other;_________________ 38. UV254 57 Molybdenum 75. TCLP-BNA’s 58. Nickel

NYC-WTC_000074672