Chain of Custody Record, Westchester County Lab, Mar 2002

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM MWchester WESTCHESTER COUNTY LABORATORIES AND RESEARCH X 2 Dana Road, Valhalla, New York 10595 1»jgj 3: (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; BUrt 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 CA,CH, Bl? Check#: Amounts

BACTERIOLOGICAL ANALYSIS Lab#;_______________________ Lab#: ^>5 ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count vstfTrihalomethanes (524) (hemodialysis & all others) __ Purgeable Halocarbons (624/8260) It^olatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw. stp) ^^TVolatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) __ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081) gs __ Microscopic __ Microextractables (504) _ PCB's (Arochlors) (608/8081) __ Macroscopic __ Pesticides/PCB screen (508) _ Herbicides (SM18/6630,8151) so _ API __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SM18/6630) 1 __ Other:_____________________ _ Herbicides (515) ___ Petroleum Hydrocarbon Scan (310-13) -C _ 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: . rng/L __ Chlorination Disinfection Byproducts (551) _ Phthalates (606MS) _j Total Chlorine Res; mg/L __ Haloacetic Acids (552) __ Other:___________________________ __ Other Pesticides (SMI8/6630) pH ___________ _UCMRList1 RADIOCHEMICAL ANALYSIS _MtBE Only (524) __ Radon __ _Other____________________ C'>

INORGANIC ANALYSIS REQUESTED - Lab#: CO -o __ Color __ Aridity __ Aluminum __ Potassiur i cm __ Turbidity __ Alkalinity __ Antimony __ Selenium c.; _ 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 CaCOa __ Calcium, as CaCOa ' __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*^ CLP __ Dissolved Oxygen __ Nitrogen, Nitrate as N _ Metals/CN __ 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 __ Solids, Suspended TCLP __ Phosphorus Total as P __ Lead __ Solids, Total _TCLP-rvIetals __ 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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