Chain of Custody Record, Westchester County Lab, Mar 2002

NYC 9/11 Public Portal Document

J •I ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 u (914)231-1620 Fax (914) 231-1772 z' 123. MYS-ELAP No. 10108 , Time/Date Set: Form A-70 (rev.10/01)

Sample Type (circle one): I s- ;',1. Potable , 3. Non Potable Treated Bottle #’s: ' .... -------- J,

2. Non Potable 4. Other Chain of Custody? Yes No Comments: I Time/Date Collected:,-~V>^ Collected By: ___2l_____ 2 Agency Code: PWS #:________ Source ID: Type Descriptor: Collected From: Bill to: I f

Location’s/lndividual's Name Name/Company Street___________ ______ Street_________ City/St/Zip ____________ City/St/Zip Identification of Source Phone#:_______ Fax#: 2. Collection Point CA.CH, Bl? Check#: Amounts

BACTERIOLOGICAL ANALYSIS Lab#: I K,'- Lab#:_______________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS X _ _ 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 (a’ll samples) __ Total Trihaldmethane Potential (510) __ Organochlorine Pesticides (608/8081) __ Microscopic __ Microextractables (504) __ PCB's (Arochlors) (608/8081) __ Macroscopic __ Pesticides/PCB screen (508) _ Herbicides (SM18/6630,8151) _-API __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SMI8/6630) __ Other:_____________________ __ Herbicjdes (515) __ Petroleum Hydrocarbon Scan (310-13) _ Pesticides (525) __ Glycols in Water Refrigerated?yes no __ Carbamate Pesticides (531) ’ __ Acid Extractables ,(625/8270) __ Glyphosate (547) __ Base Neutral Extractables (625/8270)

I Chlorinated:? . Free Chlorine Res:mg/L Total Chlorine Res:mg/L yes___ no __ Diquat (549) __ Chlorination Disinfection Byproducts (551) __ Haloacetic Acids (552) iJ' GC/MS Unknown Scan __ Phthalates (606MS) __ Other:____________________________

r' pH ___________

RADIOCHEMICAL ANALYSIS __ Radon __ Other Pesticides (SM18/6630) _UCMRList1 __ MtBE Only (524)

__ Other______ _____________ _

I- INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ /kiidity __ Aluminum __ Potassium •' Turbidity __ Alkalinity __ Antimony _L Selenium _ pH _i_ Bromide ^Arsenic Ji Silver __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium J_ Sodium bw __ Corrosivity (temp:. °C) __ Chloride __ Beryllium _L Thallium _ BOD (5 day) _ __ Cyanide __ Boron Vanadium

r __ Carbonaceous BOD (5 day) _ Soluble BOD (5 day) __ ..Chemical Oxygen Demand ■ _ Dissolved Oxygen __ Fluoride __ Hardness, Total as CaCOs __ Nitrogen, Ammonia as N __ Nitrogen, Nitrate as N __ Cadmium __ Calcium, as CaCOs __ Calcium, Ca*2 .^Chromium, Total "CLP Zinc

i_ Metals/CN

I __ Total Organic Carbon __ Total Organic Halides __ Solids, Percent (%) __ Nitrogen, Nitrite as N __ Nitrogen, Total Kjeldahl as N _ Oil and Grease __ Chromium, Hexavalent __ Cobalt __ Copper __ Volatiles I__ Semi-violatiles '__ Pesticides/PCB’s __ Solids, Settleable __ , Phenol __ Iron ICLP __ Solids, Suspended _ Phosphorus Total as P __ Lead __ TCLP-Metals __ Solids, Total __ Phosphorus, Ortho as P __ Magnesium __ TCL P-Pesticides __ Solids, Total Dissolved __ Sulfates __ Manganese __ TCL P-Herbicides __ Solids, Total Volatile __ Surfactants __ Mercury __ TCLP-Volatiles Other:_________________ _ UV254' __ Molybdenum It __ Nickel _ TCL P-BNA’s

r ■ NYC-WTC_000074927