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Chain of custody form, Westchester County Labs, undated

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Westchester County Department of Labs and Research chain of custody form for environmental samples submitted by the City DEP.

NYC-WTC_000026945–000026954

Folder label: “23900

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ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM

Ill Ulestchester County 200 - gne/DateSet:___ _________________ WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914) 593-5575 NYS-ELAP No. 10108 Form A-70 (rev. 1/96) “Wimple Type (circle one): *6 7

1. Potable 3. Non-Potable Treated Bottle #‘s: i'iy' 2. Non-Potable 4. Other ____________________ Chain of Custody? .yes no Time/Date Collected: __________ _ , Comments: Collected By: H ■ Pol_______ Agency Code: PWS#:_________ Source ID: Type Descriptor: Collected From: Bill to: Location’s/Individual’s Name. C,Z Name/Company Street 1 Street__________ City/StZip Civ/SVZio identification of Source. _AA8 Phone#: Fax#: Collection Point. &RSD 24146 CA, CH, BI? Check#: Amounts.

BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES 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 (606/8060) 4. Fecal Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8080) 5. Microscopic 6. Pesticides (507) 6. PCB’s (Arochlors) (608/8080) 6. Macroscopic 7.) Pesticides/PCB screen (508) 7. Herbicides (SM-18/6640; 8151) 7. API i 8. PCB as Decachlorobiphenyl (508A) 8. Other Pesticides (SM-18/6630) _ 9. Herbicides (515) 9. Petroleum Hydrocarbon Scan (310-13) (10. Pesticides (525) 10. Glycols in Water Refrigerated? yes no 11. Carbamate Pesticides (531) 11. Acid Extractables (625/8270) 12. Glyphosate (547) 12. Base Neutral Extractables (625/8270) Chlorinated?: 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)

pH

INORGANIC ANALYSES REQUESTED - Lab#: (circle tests) 220 0 S. Potassium

1. Color 20. Acidity 39. Aluminum 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 CaCOa 46. Calcium, as CaCO, 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-volatiles ' 12. Total Organic Halides 31. Nitrogen, Total Kjeldahl as N 50. Cobalt 69. Pesticides/PCB’s 13. Solids, Percent (%) 32. Oil and Grease 51. Copper 70. Disk Deliverables TCLP 0 Solids, Settleable 33. Phenol 52. Iron Solids, Suspended 34. Phosphorus. Total as P 53. Lead 71. TCLP-Metals ’ Solids, Total 35. Phosphorus, Ortho as P 54. Magnesium 72. TCLP-Pesticides 17. Solids, Total Dissolved 36. Sulfates 55. Manganese 73. TCLP-Herbicides 18. Solids. Total Volatile 37. Surfactants 56. Mercury 74. TCLP-Volatiles 19. Other:_____________ 38. UV254 57. Molybdenum 75. TCLP-BNA’s 58. Nickel

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NYC-WTC_000026947Source: NYC Law Department, mirrored locally

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Westchester County Department of Labs and Research chain of custody form documenting the transfer of environmental samples.

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