Chain of custody form, Westchester County Lab, Sep 2001

NYC 9/11 Public Portal Document

UI ' ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ■ WESTCHESTER COUNTY LABORATORIES AND RESEARCH

I sst pidow .-*ry CAE002DanaRoad,Valhalla,NewYork10595GonLEC19193 ■ (914)593-5575 pt f MS ! 5 n ‘* r.iv. i ! wvi. 10104 " 5 it® ' o a a / fay i )

tabeTyon.k '' 1/0145/00%7/12/.,02*0,151,00 1 Jass tet 54 ; r i- " • No eu i ip ? 37 Bottle #‘sti Le(204( — L G1521521 2. Non-Potable 4. Other__________ Chain of Custody?_____ yes ...... no" , -

Time/Date Collected: IS 9 ■ 1444 Comments:. Collected By: Agency Code: PWS #:________ . e i; ■ i vhe) i), • ripta

Collected From: Bill to: NVc -PA[ Location’s/Individual’s Name. Name/Company. Street 19 Wer I la*c D.. ______ Street 9 Chy/StZip Valka NeN2/16<9< Identification of Source ”* _______ $ : Citv/SVZi 00 ■iiil Phone#: Fax#: Collection Point Dfl 9 IASS *..'____ ' • 3P l~CA~CH~~B!? Check#? Amounts"

BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES Lab#:. Lab #: 2 2 / ■/ / (circle tests) (circle tests) 9 1. Heterotrophic Plate (1.) Trihalomethanes (524) AAN 5 . 1. Purgeable Halocarbons (624/8260) — 2 Volatile Halocarbons (524) X0,8M Count (hemodialysis & all others) 2. Purgeable Aromatics (624/8260) (3 Volatile Aromatics (524) 7 7 3. Acrolein & Acrylonitrile (624) 2. Coliform P/A (public supplies) . 3. Coliform MPN (priv well, raw, stp) 4. Total Trihalomethane Potential (510) 4. Phthalates (606/8060) 5) Microextractables (504) 5. Organochlorine Pesticides (608/8080) 4. Fecal Coliform (all samples) 4 6. Pesticides (507) .. 5. Microscopic “6. RGB's (Arochlors) (608/8080) 6. Macroscopic (7) Pesticides/PCB screen (508) 7. Herbicides (SM-18/6640; 8151) 7.APL 8. PCB as Decachlorobiphenyl (508A) 8, Other Pesticides (SM-18/6630) Other__ _____________ (9) Herbicides (515) 9. Petroleum Hydrocarbon Scan (310-13)

Remge rated? yes no 50 Pesticides (525) _ . 11. Carbamate Pesticides (531) 10. Glycols in Water 11. Acid Extractables (625/8270) (12) Glyphosate (547) 12. Base Neutral Extractables (625/8270) Chlorinated9:yes_____ no 13 Diquat (549) 13. GC/MS Unknown Scan 14. Chlorination Disinfection Byproducts (551) 14. Purgeable Halocarbons (DEF) Free Chlorine Res: __ mg/L 15. Haloacetic Acids (552) 15. Purgeable Aromatics (DEF) 16. Other Pesticides (SM-18/6630) 16. Pesticides (DEF) Total Chlorine Res: __ ______ mg/L 17. Petroleum/Hydrocarbon Scan (310-13) 17. PCB’s (Arochlors) (DEF) : or

_ 58,16)3___ INORGANIC ANALYSES REQUESTED - Lab#: (circle tests) 1. Color 20. Acidity /39. Aluminum /59) Potassium 2. Turbidity 21. Alkalinity, as CaCO3 / 40. Antimony 60. Selenium 3. pH 22. Bromide 1 41. Arsenic 61. Silver 4. Conductivity 23. Bromate/Chlorate/Chlorite | 42. Barium 62. Sodium 5. Corrosivity (temp: _°C) 24. Chloride 43./Beryllium 6. i nalline 6. BOD (5 day) 25. Cyanide 44. Boron / 64. Vanadium 7. Soluble BOD (5 day) 26. Fluoride 45) Cadmium 65.Zinc 8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCO3 46. Calcium, as CaCO3 47. Calcium, Ca'2 CLP " 9. Chemical Oxygen Demand 28. Nitrogen, Ammonia as N 66. Metals/N 10. Dissolved Oxygen /) Nil?, en, Nile 2 . P 48 Chromium, Total 6/ Val.-tile 11. Total Organic Carbon .it Nittoge* yehrap N 45* ; oam .; . o-n d ti-ni volatikos 12. Total Organic Halides A1. Nittogen, 16 r i ia . f 50. Cobait 6 Perticides/H* B 13. Solids,"Percent (%) 29 Oilandtagast. , (51. Copper 70 Dih D-livas abb* Solids, Settleable 3: Phenol 52.\Iron TCLP Solids, Suspended Te Solids, Total 34. Phosphout , ■ . F 35. Phosphorus, Ortho as P — 53, Lead _ 54. Magnesium / Ji J P Matali /. !C P-Pestrider i ii 17. Solids, Total Dissolved 36. Sulfates T . 55. Manganese I i i ( LP HHart-ktins 18. Solids, Total Volatile 19. Other: e 38.UV254 37. Surfactants 56. Mercury /.N../ t / ICi P Volatten /6 ICt- 4" aB/Nickel fn !

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