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

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ■»sa» WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 ^(J_l 1 * (914)231-1620 Fax (914) 231-1772 I 121 NYS-ELAPNo. 10108 Time/Date Set; Form A-70 (rev. 10/01)

Sample Type (circle one): 'i ■ ! ; ■ I 1. Potable 3. Non Potable Treated •Bottle #’s; I

2. Non Potable 4. Other_____________ Chain of Custody? Yes___ No Time/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#: I 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) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081) __ Fecal Coliform (all samples) __ Microscopic __ Microextractables (504) __ PCB’s (Arochlors) (608/8081) __ Macroscopic __ Pesticides/PCB screen (508) _ Herbicides (SM18/6630,8151) _ API __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SM18/6630) __ 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) __ i Base Neutral Extractables (625/8270) __ Diquat (549) GC/MS Unknown Scan I 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 _____________ _UCMRList 1 RADIOCHEMICAL ANALYSIS __ MtBE Only (524) ___ Radon _ Other_______________________

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Acidity __ Aluminum __ Potassium __ Turbidity __ Alkalinity __ Antimony __ Selenium _ pH __ Bromide __ Arsenic __ Silver __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium __ Corrosivity (temp:. .‘’C) __ Chloride __ Beryllium _ Thallium j_ BOD (5 day) __ Cyanide ‘__ Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Zinc Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOa CLP __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*2 __ Metals/CN __ Dissolved Oxygen __ Nitrogen, Nitrate as N __ Chromium, Total __ Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Semi-violatiles __ Total Organic Halides - Nitrogen, Total Kjeldahl as N _ Cobalt __ Solids, Percent (%j __ Pesticides/PCB’s __ 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 __ Solids, Total Dissolved __ Sulfates __ Manganese __ TCLP-Herbicides __ Solids, Total Volatile __ Surfactants __ Mercury _ TCLP-Volatiles __ Other:___________________ _ UV254 __ Molybdenum __ TCLP-BNAs __ Nickel k

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NYC-WTC_000074673