Chain of Custody Record, Westchester County Lab, Mar 2002

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM 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): (potable 3. Non Potable Treated Bottle #’s;____________________ 2. Non Potable 4. Other____________ Chain of Custody?___ Yes No Time/Date Collected: a.)g4.| 01- Comments;__________________ Collected By: 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. BI? Check#: Amounts

BACTERIOLOGICAL ANALYSIS Lab#; ■

Lab#:_______________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count jzTrihalomethanes (524) (hemodialysis & all others) __ Purgeable Halocarbons (624/8260) ■Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) _w/IZoIatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) __ 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 (SM18/6630,8151) _ API __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SM18/6630) __ Other:_____________________ _ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) __ 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) I Total Chlorine Res: .mg/L __ Haloacetic Acids (552) _ Other:__________________________ __ Other Pesticides (SM18/6630) pH ___________ _UCMRList1 RADIOCHEMICAL ANALYSIS _MtBE Only (524) -L-J __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#; __ Color __ Acidity __ Aluminum __ Potassii)^J __ Turbidity __ Alkalinity __ Antimony __ Selenium ' _ pH __ Bromide __ Arsenic __ Silver / c :■ __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium __ Corrosivity (temp; °C) __ Chloride __ Beryllium __ Thallium _ BOD (5 day) __ Cyanide __Boron __ Vanapium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Zinc/ C' _ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Caicium, as CaCOs CLP 1 __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*^ __ Dissolved Oxygen __ Nitrogen, Nitrate as N _ Metfels/CN __ Chromium, Total __ Total Organic Carbon _ VolMles __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Semi-violatiles __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N __ Cobalt _ Pekicides/PCB’s __ Solids, Percent (%) __ Oil and Grease __ Copper i __ Solids, Settleable __ Phenol __ .Iron __ Solids, Suspended __ Phosphorus Total as P __ Lead ICLE _ _ Solids, Total _TCLP-Metals __ 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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