Chain of Custody Record, Westchester County Lab, Mar 2002

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM MLstchester WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914) 231-1620 Fax (914) 231-1772 IMYS-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: ^0 2- 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, Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS Lab#:_______________________ __ Heterotrophic Plate Count Lab#:_ / >/ >"7 ORGANIC PO ,BLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS YlTrihalomethanes (524) __ Purgeable Halocarbons (624/8260) (hemodialysis & all others) ’‘‘Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) JZTVolatile 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) 3^ CO __ Macroscopic __ Pesticides/PCB screen (508) _ Herbicides (SM 18/6630,8151) I _ API __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SM18/6630) jr __ 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 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 -......... -...... .......................... __ UCMRListI RADIOCHEMICAL ANALYSIS _ MtBE Only (524) __ Radon __ Other______________________ ____________ a. _o INORGANIC ANALYSIS REQUESTED - Lab#: __ Color _ Acidity __ Aluminum _ Potassiunjf-A^ __ Turbidity _ Alkalinity __ Antimony __ Selenium _ 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 CaCOs __ Calcium, as CaCOs __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*2 __ Dissolved Oxygen _ Metals/CN __ Nitrogen, Nitrate as N __ 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 TCLP __ Solids, Suspended __ 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-Heri3icides __ Surfactants __ Mercury __ Other;__ ______________ _ TCLP-Volatiles _ UV254 __ Molybdenum _ TCLP-BNA’s _ _ Nickel

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