Chain of custody form, Westchester County Lab, Sep 2001

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ster vcom WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 UE I (914) 593-5575 NYS-ELAP No. 10108 Time/Date Set: Form A-70 (rev. 1/96)

Sample Type (circle one): (1 Potable 3. Non Potable Treated Bottle #s: 7 3" 22 ) 2 C 2. Non Potable 4. Other Chain of Custody? yes no Time/Date Collected: d/zo/00l __ I0"AM Comments: Collected By: S, A hpo C Agency Code: PWS#:__________ Source ID: .Type Descriptor Collected From: Bill to: Location's/Individual's Name /An Name/Company Street_____________________________________ Street___________ __________________________________________ City/St/Zip________ Identification of Source___________ 600 44“ Phone#:__________ Fax#: Collection Point____ 32/ so/ 28533 CA,CH, Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS Lab#:___________________ __ Lab#:______________________ (circle tests) (circle tests) 1. Heterotrophic Plate 1. Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260) Count (hemodialysis & all others) (2. Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260) 2. Coliform P/A (public supplies) (3 Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624) 3. Coliform MPN (priv well, raw, stp) 4. Total Trihalomethane Potential (510) 4. Phthalates (625/8270) 4. Fecal Coliform (all samples) 5. MIcroextractables (504) 5. Organochlorine Pesticides (608/8081) 5. Microscopic Pesticides (507) 6. PCB’s (Arochlors) (608/8081) 6. Macroscopic Pesticides/PCB screen (508) 7. Methoprene (616) _____ 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151) 9. Herbicides (515) 9. Pesticides (SM18/6630) Refrigerated? yes no fl” ’Pesticides (525) 11. Carbamate Pesticides (531) 10. Petroleum Hydrocarbon Scan (310-13) 11. Glycols Chlorinated:? yes no 12. Glyphosate (547) 12. Acid Extractables (625/8270) 13. Diquat (549) 13. Base Neutral Extractables (625/8270) Free Chlorine Res:. . mg/L 14. Chlorination Disinfection Byproducts (551) 14. GC/MS Semivolatile Unknown Scan Total Chlorine Res: —mg/y: " 15. Haloacetic Acids (552) ) 2 15. Purgeable Halocarbons (DEF) 16. Pesticides ($M18/6630) — . 16. Purgeable Aromatics (DEF) PH________ __ ' ath 17. Petroleum/HydrocarbonScan (310-13) 17. Pesticides/PCB’s (DEF) 12,99*9 41 iliomer=========lomr== —--=-====================-------------‘-----T1-0,*-=>**-*=////*////=====/=,//=51!"i9!=======222"=*1#-5=A#221112/"11117T1???d= INORGANIC ANALYSIS REQUESTED - Lab#: _ (circle tests) 2 27 1. Color 20. Acidity 39. Aluminum 59. Potassium 2. Turbidity 21. Alkalinity, as CaCO3 40. Antimony 60. Selenium 3. pH 22. Bromide 41. Arsenic 61. Silver 4. Conductivity 23. Bromate/Chlorate/Chlorite 42. Barium 62. Sodium 5. Corrosivity (temp:__ °C) 24. Chloride 43. Beryllium 63. Thallium 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 CaCOs CLP 9. Chemical Oxygen Demand 28. Nitrogen, Ammonia as N 47. Calcium, Ca+2 66. Metais/CN 10. Dissolved Oxygen 29. Nitrogen, Nitrate as N 48. Chromium, Total 67. Volatiles 11. Total Organic Carbon 30. Nitrogen, Nitrite as N 49. Chromium, Hexavalent 68. Semi-violatiles 12. Total Organic Halides 31. Nitrogen, Total Kjeldahl as N 50.Cobalt 69.Pesticides/PCB*s 13. Solids, Percent (%) 32. Oil an Grease 51.Copper 70. Disk Deliverables 24. Solids, Settleable 33. Phenol 52. Iron TCLP CSolids, Suspended 34. Phosphorus Total as P &.Lead 35. Phosphorus, Ortho as P 54 Magnesium 71 TCLP-Metais TO Solids, Total 72.TCLP-Pesticides 17. Solids, Total Dissolved 36. Sulfates 55 Manganese 56. Mercury 73. TCLP-Herbicides 18. Solids, Total Volatile 37. Surfactants 38. UV254 57 Molybdenum 74. TCLP-Volatiles 19. Other.________________ 75. TCLP-BNA’s 58. Nickel mat.. - ------- ------- •

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