Chain of custody record, Westchester County Department of Labs &

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ^’1 WESTCHESTER COUNTY LABORATORIES AND RESEARCH •rS 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 /NYS-ELAP No. 10108 Time/Date Set:

SarnpleType {circle one): •’ ■) Y-:’ 6,.Potable.-^ 3. Non Potable Treated Bottle #’8; ■ . -s

2. Non Potable 4. Other Chain of Custody? Yes No Tlme/Date Collected: _::£_£___2_______ Comments:

j Collect By: Agency Code; PWS#:_______ Source ID: .Type Descriptor: Collected From: Bill to: Locatlon's/lndividuai’s Name 0 -7 J 7 t Name/Cornpany _ Street ________ Street______ __ Clty/St/Zlp__________ City/St/Zlp___ Identification of Source Phone#: _ ___ Fax#: Collection Point

BACTERIOLOGICAL ANALYSIS Lab#: I CA,CH,Bl? Check#:. ____ Amount$ I Lab#: __ Heterotrophic Plate Count ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS 1 (hemodialysis & all others) __ Trihalomethanes (524) __ Purgeable Halocarbons (624^260) YY _ Coliform P/A (Public supplies) __ Volatile Halocarbons (524) _ Purgeable Aromatics (624/8280) 5,'. _ Coliform MPN (priv well, raw, stp) _ Volatile Aromatics (524) _ Acrolein & Acrylonitrile (8260) _ Fecal Coliform (all samples) __ Total Trihaiomethane Potential (510) _L Organochiorine Pesticides (608/8081) i Microscopic _ Macroscopic __ Microextractables (504) __ Pesticides/PCB screen (508) __ PCB’s .(Arochlors) (608/8081) ■ Herbicides (SMi8/6630.8151) _ Other Pesticides (SM18/6630) ' ? I API __ PCB as Decachlorobiphenyl (508A) a _ Other __ _______________ _ Herbicides (515) _ Pesticides (525) _ Petroleum Hydrocarbon Scan (310-13) Glycols in Water - I Refrigerated?yes no __ Carbamate Pesticides (531) _ Acid Extractables (625/8270) Chlorinated:? yes no -^GIyphGsat&<647)-———............... . -.:_^BaseJ4eutrai£xtractables4625/8270)---^--^ 3 Free Chlorine Res:_______ mg/L _Diquat (549) __ Chlorination Disinfection Byproducts (551) GC/MS Unknown Scan _ Phthalates (606MS) 3 V Total Chlorine Res: ______ mg/L _Haloacetic Acids (552) __ Other • pH"...-........... .. . .. _ Other Pesticides (SM18/6630) _UCMRList1 I 'W _MtBE Only (524) RADIOCHEMICAL ANALYSIS Radon Other _________ _ I INORGANIC ANALYSIS REQUESTED - Lab#: __ Color ' _ Acidity __ Aluminum __ Potassium _ Turbidity _ Alkalinity Antimony _ Selenium ■,3 _PH __ Bromide _Arsenic _Silver __ Conductivity __ Bromate/Chlorate/Chiorite _ Barium __ Sodium __ Corrosivity (temp:. .“C) _ Chloride _ Beryllium _ Thallium _ BOD (5 day) __ Cyanide __ Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium _Z!nc _ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOs __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*2 CLE __ Dissolved Oxygen _Metals/CN __ Nitrogen, Nitrate as N _Chromium, Total _ Volatiles __ Total Organic Carbon _ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Semi-vfolatlles __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N _Cobatt __ Solids, Percent (%) _ Pesticides/PCB’s __ Oil and Grease __ Copper __ Solids, Settleable __ Phenol Iron __ Solids, Suspended __ Phosphorus Total as P Lead ISLE _TCLP-Metal8 __ Solids, Total __ Phosphorus, Ortho as P __ Magnesium _TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates __ Manganese _ Solids, Total Volatile _TCLP-Herbicides __ Surfactants __ Mercury _TCLP-Volatile8> Other: 5 ______ _ UV254 __ Mo^bdeniBn _ TCLP-BNA’s " _ Nickel

NYC-WTC_000074997