Chain of custody record, Westchester County Department of Labs &

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM 3 '!-2« IS & /.com 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: FormA.70(rev:10/01) S

^sample Type (circle one): ^Potable

2. Non Potable , ; 3. Non Potable T/eafed

4-Qttier ________ / / ■ Bottle #'s:. Chain of Custody?Yes.No I Time/Date Coll Comments: _ __________________ ______ ■ - .■ Collected By: » ^Fr^^/^Agency Code: PWS#:___ __ Source ID: Type Descriptor: Collected From: ; Bill to: •a < ■

: Lotation’s/lndividual^Name, Name/Company ... Street__________ __X- City/St/Zip __________ _1_ Street ___ City/St/Zlp___ 8 I Identification of Source ___ / Collection Point _____ 7? Phone#: _____ ; I CA.CH. Bl? Check#: Fax#:

Amount$ i BACTERIOLOGICAL ANALYSIS Late#: I Lab#: ORGANIC NONPOTABLE/SOLID ANALYSIS 1 ORGANIC POTABLE ANALYSIS _ Heterotrophic Plate Count (hemodialysis & all others) _TrihaIomethanes (524) __ Volatile Halocarbons (524) Purgeable Halocarbons (624/8260) s J _ Purgeable Aromatics (624/8260) ' I I _ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) __ . Fecal Coliform (all samples) __ Volatile Aromatics (524) __ Total Trihalomethane Potential (510) _ MIcroextractables (504) , _ Acrolein & Acrylonitrile (8260) Y _ OrganochloHrte Pesticides (608«0Q1) s ’/ _ PCB’s (Arochlors) (608/8(381) -7^ • Ia I _ Microscopic _ Macroscopic _ Pesticides/PCB screen (508) __ Herbicides (SM18/6630,8151) 3 _ API _ Other________ _ __ PCB as Decachlorobiphenyi (508A) _ Herbicides (515) _ Pesticides (525) _ Other Pesticides (SM18/^F\,<Y;W _ Peholeum Hydrocarbon Scan (31O-13) _ Glycols in V\fater . 'Ss- 3 Refrigerated?yes _ no _ Carbamate Pesticides (531) . AcidExtractables (625/8270) - Chlorinated:?........ ves no __ Glyphosate (547)--------------------------- Z^Jase Neutral Extractabies<625/8270)-— _ Diquat (549) I J^GC/MS Unknown Scan Free Chlorine Res: .mg/L _Chlorinaflon Disinfection Byproducts (551) _ Phthalates (606MS) Total Chlorine Res: . mg/L __ Haloacetic Acids (552) _ Ofrier: I- i3H;_^__ ___ _ Other Pesticides (SM18/6630) _UCMRList1 —— RADIOCHEMICAL ANALYSIS _MtBE Only (524) \ ” _Radon _ Other._______________ _ ■- Y .............................................. i I. I II

1 INORGANIC ANALYSIS REQUESTED - Lab#: __ Color _ Acidity Sie _^^uminum __ Potessium ^'3

_ Turbidity _ Alkalinity _I/Aritltoony _i^.8elenlum — pH __ Bromide u^Araerrie ^Silver __ Conductivity __ BromateZChiorate/Chiorite _ifBarium __ Sodium _ Corrosivity (temp:____®C) _ Chloride Ji Beryllium ^Thallium _ BOD (5 day) __ Cyanide _ Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium -ix^nc _ Soluble BOD (5 day) __ Hardr||^, Total as CaCOs __ Calcium, as CaCOs __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N CUB __ Calcium, Ca*2 ‘.i

__ Dissolved Oxygen __ Nitrogen, Nitrate as N _^hromium. Total _Metals/CN __ Total Organic Carbon Nitrogen, Nitrite as N _ Volatiles __ Chromium, Hexavalent _ Total Organic Halides __ Nitrogen, Total l^eldahl as N .^Cobalt __ Semi-violatiles _ Solids, Perde^3(%)' _ Pesticldes/PCB’s _ . Oil and Grease .(^Copper _ Solids, Settleable __Phenol _ulron _ Solids, Suspended TCLP __ Phosphorus Total as P _^Lead _ Solids, Total __ Phosphorus, Ortho as P _TCLP-Metals __ Magnesium _ Solids, Total Dissolved __ Sulfates _TCLP-Pestlcides p Manganese _TCLP-Herblcides _ Solids, Total Volatile __ Surfactants Mercury _ TCLP-Volatiles' .STv—- _ UV254 .^Molybdenum Nickel _TCLP-BNA's

NYC-WTC_000075003