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-ELAPNo. 10108 Time/Date Set: Form A-70 (rev. 10/01)

Sample Type (circle one): ^T^otable 3. Non Potable Treated Bottle #'s; 2. Non Potable 4. Other Chain of Custody? Yes___ No Time/Date Collected: _ Comments: Collected By: | Agency Code: PWS #:________ Source ID: Type Descriptor: Collected From: Bill to; Location’s/lndividual’s Name Name/Company Street _ _____________________ Street_________ City/SVZip___________________ City/SUZip 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 jZTrihalomethanes (524) (hemodialysis & all others) __ Purgeable Halocarbons (624/8260) J</olatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) vXVolatile 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 (SM18/6630,8151) _ API __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SMI 8/6630) __ Other;_____________________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) _ Pesticides (525) __ Glycols in Water Refrigerated?yes no __ Carbamate Pesticides (531) _ Acid Extractabtes (625/8270) Chlorinated:?yes no __ Glyphosate (547) __ Base Neutral Extractabtes (625/8270) so __ Diquat (549) __ GC/MS Unknown Scan I Free Chlorine Res: . mg/L __ Chlorination Disinfection Byproducts (551) __ Phthalates (606MS) Total Chlorine Res: .mg/L __ Haloacetic Acids (552) __ Other:__________________________ Other Pesticides (SM18/6630) pH ___________ __ UCMRListI RADIOCHEMICAL ANALYSIS _ MtBE Only (524) L.J __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#; __ Color __ Acidity __ Aluminum __ Potassium __ Turbidity _ Alkalinity __ Antimony __ Selenium _ pH __ Bromide __ Arsenic __ Silver I CV c __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodiurw-^ CJ __ Corrosivity (temp: ’C) __ Chloride __ Beryllium _ ThalliJm 'op _ BOD (5 day) __ Cyanide __Boron __ Vanamum *< -Cr _ _ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Zinc J _ Soluble BOD (5 day) __ Hardness. Total as CaCOa __ Calcium, as CaCOa CLP / __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*2 __ Dissolved Oxygen __ Metds/CN __ Nitrogen, Nitrate as N __ Chromium, Total __ Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Serni-violatiles __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N __ Cobalt __ Solids, Percent (%) __ Pesticides/PCB’s __ Oil and Grease __ Copper __ Solids, Settleable __ Phenol __ .Iron ___ Solids, Suspended __ Phosphorus Total as P ICL£ __ Lead _ _ Solids, Total _TCLP-N!etals __ 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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