Chain of Custody Record, Westchester County Lab, Mar 2002

NYC 9/11 Public Portal Document

xT T ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM :hester WESTCHESTER COUNTY LABORATORIES AND RESEARCH igovcom 2 Dana Road, Valhalla, New York 10595 at 9 (914)231-1620 Fax (914) 231-1772 NYS-ELAP No. 10108 Time/Date Set: Form A-70 (rev. 10/01)

Sample Type (circle one): ^^otable 3. Non Potable Treated Bottle #’s: 2. Non Potable 4. Other____________ Chain of Custody? Yes___ No Time/Date Collected: Comments: Collected By: Tt&P j 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_____________ ------------- I CA,CH, Bl? Check#: Amounts

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:_______________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count i^Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) (hemodialysis & all others) JzfVolatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) .ji^VoIatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) __ Coliform MPN (priv well, raw, stp) __ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081) __ Microscopic __ Microextractables (504) _ PCB’s (Arochlors) (608/8081) __ Macroscopic __ Pesticides/PCB screen (508) _ Herbicides (SMI8/6630,8151) __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SMI 8/6630) __ API 33 __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) 3»l __ Other:_____________________ : __ Pesticides (525) __ Glycols in Water •33 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 > Free Chlorine Res:mg/L __ Chlorination Disinfection Byproducts (551) _ Phthalates (606MS) Total Chlorine Res:mg/L __ Haloacetic Acids (552) __ Other:_________________________ _ Other Pesticides (SM18/6630) to pH ___________ __ UCMR List 1 RADIOCHEMICAL ANALYSIS _ MtBE Only (524) Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: O __ Color __ Acidity __ Aluminum __ Potassiuff __ Turbidity __ Alkalinity __ Antimony __ Selenium CD _ pH __ Bromide __ Arsenic __ Silver I __ Bromate/Chlorate/Chlorite __ Sodium/ -< 4=- __ Conductivity __ Barium __ Corrosivity (temp:. .°C) __ Chloride __ Beryllium __ Thailiurh _ BOD (5 day) __ Cyanide __ Boron _ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Zinc I _ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOa __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*2 Se / _ Metal^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 __ 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 __ Manganese _TCLP-Herbicides _ Solids, Total Volatile __ Surfactants __ Mercury _ TCLP-Volatiles __ Other:_________________ _ UV254 __ Molybdenum _ TCLP-BNA’s „ Nickel

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