Chain of Custody Record, Westchester County Lab, Mar 2002

NYC 9/11 Public Portal Document

I ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH ft: 2 Dana Road, Valhalla, New York 10595 / ■ (914)231-1620 Fax (914) 231-1772 NYS-ELAP No. 10108 L Time/Date Set: Form A-70 (rev. 10/01)

Sample Type (circle one): ( t 1. Potable 3. Non Potable Treated Bottle #’s: / 2. Non Potable 4. Other _ __________ Chain of Custody? Yes___ No Time/Date Collected; Comments: Collected By: Agency Code: PWS #:________ Source ID: Type Descriptor: Collected From: Bill to: Location’s/lndividual’s Name Name/Company Street_________ :i Street_________________ City/St/Zip______________ City/St/Zip ST, i- Identification of Source Phone#:_______ Fax#: Collection Point Check#: Amounts. CA,CH, Bl?

I BACTERIOLOGICAL ANALYSIS Lab#: Lab#:_______________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count __ 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) __ Volatile 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) n _ API __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SMI8/6630) 1. __ 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) __ Diquat (549) _1“ GC/MS Unknown Scan Free Chlorine Res: mg/L __ Chlorination Disinfection Byproducts (551) _ Phthalates (606MS) i Total Chlorine Res: _ mg/L __ Haloacetic Acids (552) __ Other:____________________________ S’, __ Other Pesticides (SMI8/6630) J pH ___________ _UCMRList 1 RADIOCHEMICAL ANALYSIS _MtBEOnly (524) __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED ■ Lab#: ( __ Color __ Acidity __ Aluminum __ Potassium ST __ Turbidity __ Alkalinity _ .Antimony __ Selenium _ pH __ Bromide __ Arsenic (__ Silyer __ Conductivity __ Bromate/Chlorate/Chlorite~ __ Barium __ Sodium __ Corrosivity (temp:. °C) __ Chloride __ Berylliurh __ Thallium _ BOD (5 day) __ Cyanide .■ Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Zin c _ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOa "CLP __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*’ __ Metals/CN __ 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 DissoNed __ Sulfates __ Manganese __ TCLP-Herbicides __ Solids, Total Volatile __ Surfactants __ Mercury . __ TC LP-Volatiles __ Other:_________________ _ UV254 . __ Molybdenum _ TCLP-BNA’s Nickel I ( NYC-WTC_000074926