Chain of custody form, Westchester County Lab, Sep 2001

NYC 9/11 Public Portal Document

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

Sample Type (circle one): 4532,6528,0283,00", 5700, 1820 OPotable 3. Non Potable Treated Bottle #s: 45*3,8S3D 883/88128503 2. Non Potable 4. Other _____ ____________ Chain of Custody? yes nd Time/Date Collected: 4/2l/2n0/ (234 Comments: Collected By: Bessowces Agency Code: PWS#:_______ Source ID: .Type Descriptor: Collected From: Bill to: Location's/ndividual's Name (wS Name/Company _ Street_____________ __ Street________ City/St/Zip_ ___________ City/St/Zip Identification of Source Phone#:______ Fax#: Collection Point 41550 CA,CH, Bl? Check#: Amounts

BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS— ORGANIC NONPOTABLE/ SOLID ANALYSIS Lab#:___________________ _ (circle tests) (circle tests) 2 2 C 4< 1. Heterotrophic Plate 1Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260) Count (hemodialysis & all others) .2.3/olatile Halocarbons (524) 2. Purgeable Aromatics (624/8260) 2. Coliform P/A (public supplies) 3.Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624) 3. Coliform MPN (privwell, 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 6. Pesticides (507) 6. PCB’s (Arochlors) (608/8081) 6, Macroscopic 7.Pesticides/PCB screen (508) 7. Methoprene (616) hr_________ 8. PCB as Decachlorobiphenyl (508A) 9. Herbicides (515) 8. Herbicides (EPA1978/8151) 9. Pesticides (SM18/6630) Refrigerated? yes no 10 Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13) 11. Carbamate Pesticides (531) 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 E 15. Haloacetic Acids (552) 15. Purgeable Halocarbons (DEF) C. Total Chlorine Res: mg/L 16. Pesticides (SM18/6630) 16. Purgeable Aromatics (DEF) pH 17. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB's (DEF) 18. Other_______________________ • 18. _ ___________________________ w INORGANIC ANALYSIS REQUESTED - Lab#: (circle teste) 1. Color 20. Acidity 39. Aluminum 59. Potassium 3 C 2. Turbidity 21. Alkalinity, as CaCOs 40. Antimony x 60. Selenium 3. pH 22. Bromide 41. Arsenic 61. Silver C 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 CaCOs 46. Calcium, as CaCOs CLP 9. Chemical Oxygen Demand 28. Nitrogen, Ammonia as N 47. Calcium, Ca+Z 66. Metals/CN 29. Nitrogen, Nitrate as N 48. Chromium, Total SJ 10. Dissolved Oxygen 67. Volatiles 11. Total Organic Carbon 30. Nitrogen, Nitrite as N 49. Chromium, Hexavalent 68. Semi-volatiles 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 a Solids, Settleable 33. Phenol 52. Iron TCLP CSolids, Suspended 34. Phosphorus Total as P 53.Lead 71 .TCLP-Metals 16. Solids, Total 35. Phosphorus, Ortho as P 54 Magnesium 36. Sulfates 55 Manganese 72. TCLP-Pesticides 17. Solids, Total Dissolved 73. TCLP-Herbicides 18. Solids, Total Volatile 37. Surfactants 56. Mercury 38. UV254 57 Molybdenum 74. TCLP-Volatiles 19. Other________________ 75.TCLP-BNAs 58. Nickel

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