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): J^otable 3. Non Potable Treated Bottle #’s: 2. Non Potable 4. Other Chain of Custody? Yes No Time/Date Collected; Comments: Collected By: "bYT-P | BLZX 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 ^3. CA,CH. Bl? Check#; Amounts.

BACTERIOLOGICAL ANALYSIS Lab#: Lab#;_______________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count v^STrihalomethanes (524) (hemodialysis & all others) __ Purgeable Halocarbons (624/8260) _;iTVolatiIe Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) _iez^o!atile 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) __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) S __Other;___________________ _ Pesticides (525) __ Glycols in Water 1 Refrigerated?yes___ no __ Carbamate Pesticides (531) X? _ 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:__________ UJ __ Other Pesticides (SMI8/6630) pH ___________ _UCMRList1 RADIOCHEMICAL ANALYSIS __ MtBE Only (524) __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Acidity __ Aluminum __ Potassium c5 — __ Turbidity __ Alkalinity __ Antimony __ Seleniui i CD -O _ pH __ Bromide __ Arsenic __ Silver -< cn __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium . _ Corrosivity (temp: ’C) __ Chloride __ Beryllium __ Thalli urn _ BOD (5 day) __ Cyanide __Boron _Vanaditim __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Zinc ' _ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOs CLP __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium. Ca*2 __ Dissolved Oxygen __ Nitrogen, Nitrate as N __ Metals/CN __ Chromium, Total __ Total Organic Carbon _ Volatiles __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Semi-violatiles __ Total Organic Halides __ 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-Herbicides __ Surfactants __ Mercury __ Other;_________________ _ TCLP-Volatiles _ UV254 __ Molybdenum _ TCLP-BNA’s Nickel

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