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)

S^pIeType (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; jSJxP | 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^ip Identiffcation of Source Phone#:_______ Fax#: Collection Point -3 g. CA.CH, Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:_______________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count 2::^Trihalomethanes (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) jrifVolatile 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) __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SM18/6630) __ API __ Other:_____________________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) __ Pesticides (525) __ Glycols in Water Refrigerated?yes no __ .Carbamate Pesticides (531) _ Acid Extractables (625/8270) I Chlorinated:?yes _ no __ Glyphosate (547) __ Base Neutral Extractables (625/8270) __ Diquat (549) __ GC/MS Unknown Scan Free Chlorine Res: _ tng/L __ Chlorination Disinfection Byproducts (551) _ Phthalates (606MS) Total Chlorine Res: _ mg/L __ Haloacetic Acids (552) __ Other:__________________________ __ Other Pesticides (SMI8/6630) pH ___________ _UCMRList1 00 RADIOCHEMICAL ANALYSIS __ MtBE Only (524) __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#; __ Color __ Acidity __ Aluminum __ Potassium __ Turbidity __ Alkalinity __ Antimony __ Selenium o - . _ pH __ Bromide __ Arsenic __ Silver I CXI -O __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodiurn ~< O- __ Corrosivity (temp: .°C) __ Chloride __ Beryllium __ Thallium _ BOD (5 day) __ Cyanide __ Boron __ Vanadnjm __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium Zinc I __ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOs __ Chemical Oxygen Demand CLP / _ Meta^CN __ Nitrogen, Ammonia as N __ Calcium, Ca*^ _ _ Dissolved Oxygen __ Nitrogen, Nitrate as N __ Chromium, Total __ Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Semi-violatiles __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N __ Cobalt __ Pesticides/PCB's __ Solids, Percent (%) __ Oil and Grease __ Copper __ Solids, Settleable __ Phenol __ Iron TCLP __ Solids, Suspended __ Phosphorus Total as P __ Lead _TCLP-Metals __ Solids, Total __ Phosphorus, Ortho as P __ Magnesium __ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates __ Manganese __ TCLP- Herbicides _ Solids, Total Volatile ;__Surfactants __ Mercury _ TCLP-Volatiles __ Other;_________________ _ UV254 __ Molybdenum _ TCLP-BNA’s __ Nickel

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