Chain of Custody Record, Westchester County Lab, Mar 2002

NYC 9/11 Public Portal Document

viasis» 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); (^Potable 3. Non Potable Treated Bottle #'s: 2. Non Potable 4. Other Chain of Custody? Yes___ No Time/Date Collected: Comments: Collected By; 'TXsP/ 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 .yo CA,CH. Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS Lab#: Lab#;_______________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count _v4rihalomethanes (524) (hemodialysis & all others) __ Purgeable Halocarbons (624/8260) •‘-Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) ^•^olatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) __ Coliform MPN (priv well, raw, stp) __ _Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081) __ Microextractables (504) _ PCB's (Arochlors) (608/8081) __ Microscopic __ Macroscopic __ Pesticides/PCB screen (508) __ PCB as Decachlorobiphenyl (508A) _ Herbicides (SM18/6630,8151) _ Other Pesticides (SM18/6630) I ii _ API __ Other:_____________________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) __ Pesticides (525) __ Glycols in Wafer 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 L. 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 ___________ _UCMRList1 RADIOCHEMICAL ANALYSIS _MtBE Only (524) Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#; CD ..r __ Color __ Acidity __ Aluminum __ Potassium ~< O’ __ Turbidity __ Alkalinity __ Antimony __ Selenium O'. _ 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 CLP __ 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 __ 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 _TCLP-IVetals __ Solids, Total ___ Phosphorus, Ortho as P __ Magnesium __ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates __ Manganese __ Solids, Total Volatile __ TCLP-Herbicides __ Surfactants __ Mercury __ Other:_________________ _ TCLP-Volatiles „ UV254 __ Molybdenum _ TCLP-BNA's __ Nickel

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