Chain of Custody Record, Westchester County Lab, Mar 2002

NYC 9/11 Public Portal Document ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM

MM™ WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road. Valhalla. New York 10595 (914)231-1620 Fax (914) 231-1772 •X

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: Comments; Collected By: Bkj Agency Code: PWS #;________ Source ID: Type Descriptor: Collected From: Bill to: Location's/lndividuars 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 (hemodialysis & all others) j,si<rrihalomethanes (524) __ Purgeable Halocarbons (624/8260) .^Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) j=i^olatile 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 (SMI8/6630,8151) _ 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) S. __ Diquat (549) __ GC/MS Unknown Scan Free Chlorine Res: .mg/L __ Chlorination Disinfection Byproducts (551) J" _ Phthalates (606MS) Total Chlorine Res: . mg/L __ Haloacetic Acids (552) __ Other:__________________________ __ Other Pesticides (SMI 8/6630) pH ___________ _UCMRList1 RADIOCHEMICAL ANALYSIS _MtBE Only (524) U) __ Radon __ Other '_______________

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Acidity __ Aluminum __ Potassium __ Turbidity __ Alkalinity __ Antimony __ Selenium; _ pH __ Bromide __ Arsenic __ Silver i __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium j __ Corrosivity (temp;. “C) _ Chloride __ Beryllium __ Thallium/ _ BOD (5 day) __ Cyanide __Boron __ Vanadium o- __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Zinc ' I _ Soluble BOD (5 day) __ Hardness. Total as CaCOa __ Calcium, as CaCOs £LP h __ 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-v/olatiles __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N _ Cobalt __ Solids, Percent (%) __ Pesticices/PCS's __ Oil and Grease ___ Copper __ Solids, Settleable __ Phenol __ Iron __ Solids, Suspended tclp __ Phosphorus Total as P __ Lead __ Solids, Total „TCLP-Mefals __ 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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