Chain of Custody Record, Westchester County Lab, Mar 2002

NYC 9/11 Public Portal Document ACCg. ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM M^stchester 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.lO/OI)

Sample Type (circle one): ^Potable 3. Non Potable Treated Bottle #’s: 2. Non Potable 4. Other Chain of Custody? Yes No Time/Date Collected;_ _________ Comments; Collected By: gtJ-^ Agency Code; PWS #;_______ _ Source ID: Type Descriptor Collected From: Bill to: Location’s/Individual’s Name Name/Company „ Street__________________ Street_________ City/St/Zip______________ City/St/Zip Identification of Source Phone#;_______ Fax#: Collection Point CA.CH, Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:_______________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count _4e^halomethanes (524) (hemodialysis & all others) __ Purgeable Halocarbons (624/8260) _s-Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) ^^olatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) Pm.:. C2st> __ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081) CU7 __ Microscopic __ Microextractables (504) _ PCB’s (Arochlors) (608/8081) __ Pesticides/PCB screen (508) _ Herbicides (SM18/6630.8151) x-- __ Macroscopic _ API __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SM18/6630) t __ Other;_____________________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) XT _ Pesticides (525) __ Glycols in Water 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 co 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 ___________ _UCMRList1 RADIOCHEMICAL ANALYSIS __ MtBE Only (524) __ Radon __ Other____________________ o INORGANIC ANALYSIS REQUESTED - Lab#: CD __ Color __ Acidity __ Aluminum __ Potassiurr -< CJI __ Turbidity __ Alkalinity __ Antimony __ Selenium U-J — pH __ Bromide __ Arsenic __ Silver __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium __ Corrosivity (temp: .*’C) __ Chloride __ Beryllium __ Thallium _ BOD (5 day) __ Cyanide __ Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Zinc __ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOs __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*^ CLE __ Dissolved Oxygen __ Nitrogen, Nitrate as N __ Metals/CN __ Chromium, Total __ Total Organic Carbon __ Volatiles __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Total Organic Halides __ Semi-violatiles __ Nitrogen, Total Kjeldahl as N __ Cobalt __ Solids, Percent (%) __ Pesticides/PCB’s __ Oil and Grease __ Copper __ Solids, Settleable __ Phenol __ Iron __ Solids, Suspended ICL£ __ Phosphorus Total as P __ Lead __ Solids, Total _TCLP-Metals __ Phosphorus. Ortho as P __ Magnesium __ Solids, Total Dissolved _TCLP-Pesticides __ Sulfates __ Manganese _ Solids, Total Volatile _TCLP-Herbicides ___ Surfactants __ Mercury __ Other:_________________ _ TCLP-Volatiles _ UV254 __ Molybdenum _ TCLP-BNA’s __ Nickel

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