Chain of custody form, NYC DEP sample AE05062, Mar 2002

NYC 9/11 Public Portal Document

13, i ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM AVestchester WESTCHESTER COUNTY LABORATORIES AND RESEARCH, 2 Dana Road, Valhalla, New York 10595 (914) 231-1620 Fax (914) 231-1772 /'I A

NYS-ELAP No. 10108 Time/Date Set; Form A-70 (rev, 10/01) i. Sample Type (circle one); 1. Potable 3. Non Potable Treated Bottle #’s: 2. Non Potable 4. Other____________ Chain of Custody? Yes No Comments: t Time/Date Collected: Collected By: Agency Code: PWS #:________ Source ID: Type Descriptor: Collected From: Bill to: Location’s/lndividual’s Name Name/Company c- Street_________ Street_________________ City/St/Zip__________ ' City/St/Zip Identification of Source Phone#:_______ Fax#: Collection Point I 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) __ Microextractables (504) __ PCB’s (Arochlors) (608/8081) __ Microscopic __ Pesticides/PCB screen (508) _ Herbicides (SMI 8/6630,8151) __ Macroscopic __ PCB as Decachlorobiphenyl (508A) _ , Other Pesticides (SMI 8/6630) _ API __ Herbicides (515) __ Petroleum Hydrocarbon Scan '(310-13) __ Other:____________________ __ Pesticides (525) __ Glycols in Water Refrigerated?yes___ no __ Carbamate Pesticides (531) __ Acid Extractables (625/8270)

V-i- Chlorinated:?yes___ no Free Chlorine Res:mg/L _ Glyphosate (547) __ Diquat (549) __ Chlorination Disinfection Byproducts (551) __ Base Neutral Extractables (625/8270) X GC/MS Unknown Scan __ Phthalates (606MS) k

. I Total Chlorine Res:mg/L __ Haloacetic Acids (552) __ Other:_____________ _Other Pesticides (SMI8/6630) i pH ___________ _UCMR List 1 _ MtBE Only (524) RADIOCHEMICAL ANALYSIS ___ Radon ' Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: \ Color ■ Acidity __ Aluminum __ Potassium _L Turbidity __ Alkalinity __ Antimony __ Selenium _1 pH _ Bromide __ Arsenic __ Silver __' Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium __ \Corrosivity (temp:. °C) __ Chloride __ Beryllium __ Thallium _ BOD (5 day) __ Cyanide __ Boron __ Vanadium _L_ Carbonaceous BOD (5 day) __ Fluoride __ Cadmjum __ Zinc _ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOs CLP __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*^ _Metals/CN __ Dissolved Oxygen __ Nitrogen, Nitrate as N 2_Chromium, Total __ Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Semi-violatiles _ _ Total Organic Halides I__ 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 _TCLF»-Metals __ Solids, Total __ Phosphorus, Ortho as P __ Magnesium __ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates __ Manganese __ TCLP-Herbicides __ Solids;'* Total Volatile _2_ Surfactants __ Mercury __ Other:'._________________ __ TCLP-Volatiles _ UV254 __ Molybdenum _ TCLP-BNAs __ Nickel

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