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

NYC 9/11 Public Portal Document

ACCn ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM. ^Westchester WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York '10595 , (914)231-1620 Fax (914) 231-1772 NYS-ELAP No. 10108 Time/Date Set: ( Form A-70 (rev. 10/01)

Sample Type (circle one): ' "I •X’ \ ' • ■f Quotable./ 3. Non Potable Treated Bottle #’s:

2. Non Potable 4. Other Chain of Custody? Yes No •i. Time/Date Collected:_____________________ Comments: Source ID: * Collected By: • - Agency Code: PWS #:_________ Type Descriptor:

Collected From: Bill to:

Location’s/lndividual's Name Name/Company

Street____________________ Street__________ City/St/Zip _ ______________ Citv/St/Zio

Identification of Source Phone#:________ Fax#: - S’" Collection Point CA,CH, Bl? Check#: Amounts. I

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) __ Volatile Aromatics (524) __ Acrolein ’& Acrylonitrile (8260) _ _ Coliform MPN (priv well, raw, stp)' __ Total Trihalomethane Potential (510) __ 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 (SM18/6630) _ API __ Other:________________________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) F __ Pesticides (525) __ Glycols in Water F 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 V • Free Chlorine Res:mg/L __ Chlorination Disinfection Byproducts (551) _ Phthalates (606MS) Total Chlorine Res:mg/L __ Haloacetic Acids (552) ' _ Other:J________________________ _Other Pesticides (SMI8/6630) pH _____________ _UCMRList1 I- RADIOCHEMICAL ANALYSIS ___ Radon _MtBE Only (524) 1

__ Other________ _ _____________

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Acidity '•/ Aluminum __ Potassium __ Turbidity __ Alkalinity / Antimony Selenium f- _ pH __ Bromide Y Arsenic -■ Silver __ Conductivity . __ Bromate/Chlorate/Chlorite Barium . Sodium __ Corrosivity (temp:. .°C) _ Chloride / Beryllium ■Y Thallium f _ BOD (5 day) __ Cyanide __ Boron ___Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium _L' Zinc ___ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOa CLP __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*2 i __ Dissolved Oxygen __ Total Organic Carbon __ Nitrogen, Nitrate as N __ Nitrogen, Nitrite as N J_Chromium, Total __ Chromium, Hexavalent t _ Meta Is/CN __ Volatiles __ Semi-violatiles X,' __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N X Cobalt I _ Solids, Percent (%) __ Solids, Settleable __ Oil and Grease __ Phenol ■ Copper Iron __ Pesti cides/PCB’s

TCLP __ Solids, Suspended __ Phosphorus Total as P Lead I __ TCLP-Metals __ Solids, Total __ Phosphorus, Ortho as P __ Magnesium __ TCLP-Pesticides _ Solids, Total Dissolved __ Sulfates Y. Manganese __ TCLP-Herbicides ___Solids, Total Volatile __ Surfactants Mercury 2/ Other: ■ __ _ TCLP-Volatiles _ UV254 _L Molybdenum _ TCLP-BNA's 7 Nickel I

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NYC-WTC_000074693