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

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ^festclieste- WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 u Eh (914) 231-1620 Fax (914)231-1772 J-’’

NYS-ELAP No. 10108 Time/Date Set: Form A-70 (rev. 10/01) A' Sample Type (circle one). <'l_^otable’ 3. Non Potable treated Bottle #’s: Yes___ No ' 2. Non Potable 4. Other Chain of Custody? i Time/Date Collected: Comments:

Collected By: - ‘• Agency Code: PWS #:_________ Source ID: Type Descriptor: f Bill to: Collected From: I Location’s/lndividual’s Name. Name/Company ! Street__________ Street_____ _______________ City/St/Zip_________________ City/St/Zip V h' Identification of Source Phone#:________ Fax#: _i a, T Collection Point CA,CH, Bl? Check#: Amounts I

/•' Lab#: BACTERIOLOGICAL ANALYSIS 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) i'' _ Coliform MPN (priv well, raw, stp) __ Volatile Aromatics (524) ___ Total Trihalomethane Potential (510) __ Acrolein & Acrylonitrile (8260) __ Organochlorine Pesticides (608/8081) ___ Fecal Coliform_ (all samples) __ Microextractables (504) _ PCB’s (Arochlors) (608/8081) __ Microscopic ___ Pesticides/PCB screen (508) __ Herbicides (SM18/6630,8151), __ Macroscopic __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SMI8/6630) _ API __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) _ Other: _i____________________ f- Refrigerated?yes no __ Pesticides (525) __ Carbamate Pesticides (531) __ Glycols in Water ___ Acid Extractables (625/8270) _ Glyphosate (547) __ Base Neutral Extractables (625/8270) F ' A ■■ Chlorinated:? ; yes___ ho __ 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 _ ____________ __ UCMR List 1 RADIOCHEMICAL ANALYSIS _MtBEOnly (524) j__ Radon , __ Other_________________ __

p INORGANIC ANALYSIS REQUESTED - Lab#: fe 1 L __ Color __ /k;idity Y Aluminum __ Potassium __ Turbidity __ Alkalinity Antimony Selenium » — pH __ Bromide Arsenic Silver 1__ - Conductivity __ Bromate/Chlorate/Chlorite ./ Barium - Sodium __ Corrosivity (temp:. °C) __ Chloride Beryllium Thallium A_ BOD (5 day) ___ Cyanide __ Boron __ Vanadium J__ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium jY Zinc Y _ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOa CLP _J_ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*2 _ Meta Is/CN \ Dissolved Oxygen __ Nitrogen, Nitrate as N iZChromium, Total __ 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 __ Solids, Total Dissolved __ Sulfates jY Manganese __ TCLP-Herbicides ___Solids, Total Volatile __ Surfactants __j Mercury _ TCLP-Volatiles Y Other: - : ■■____________ _ UV254 __ Molybdenum i _ TCLP-BNA's- t ---------------------------------- _i Nickel

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