Chain of custody record, Westchester County Lab

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH

Uoncnenter county 2 Dana Road, Valhalla, New York 10595 (914) 593-5575 NYS-ELAP No. 10108 “a/Date Set:______ Form A-70 (rev. 1/96) Sample Type (circle one): 719,7513. IS 16. 1 Potable 3. Non-Potable Treated Bottle #‘s: (140, 1"** * # 11.m 2. Non-Potable 4. Other.___________ Chain of Custody? yes ____ no Time/Date Collected:. w/7 (2 col 5:55 Comments: Collected By: M I ACO’S Agency Code: PWS#:________ .Source ID:. Type Descriptor. Collected From: Bill to: Location’s/Individual’s Name_____ Name/Company Street______________________ Street_________ City/St/Zip___________________ City/St/Zip Identification of Source_________ Phone#:_ Fax #: Collection Point B . B CA, CH, BI? Check#: Amounts . w

BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES Lab#:_____ __ ________ ___ Lab #: Le (circle tests) . (circle tests) 1. Heterotrophic Plate Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260) Count (hemodialysis & all others) Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260) 5 2. Coliform P/A (public supplies) 3. Coliform MPN (priv well, raw, stp) 3 Volatile Aromatics (524) 4. Total Trihalomethane Potential (510) 3. Acrolein & Acrylonitrile (624) 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) 8. PCB as Decachlorobiphenyl (508A) 8. Other Pesticides (SM-18/6630) er:% 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) c • W no 12. Glyphosate (547) 13. Diquat (549) 12. Base Neutral Extractables (625/8270) 13JGC/MS Unknown Scan '.Chlorinated?: yes. j 14. Chlorination Disinfection Byproducts (551) 14. Purgeable Halocarbons (DEF) Free Chlonne 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) A 3 1. Color 20. Acidity 39. Aluminum 59. Potassium 2. T urbidity 21. Alkalinity, as CaCOa 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 CaCOa CLP 9. Chemical Oxygen Demand 28. Nitrogen, Ammonia as N 47. Calcium, Ca*2 66. Metals/CN H 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 12Solids, Percent (%) 32. Oil and Grease 51. Copper 70. Disk Deliverables olids. Settleable 33. Phenol 52. Iron TCLP 15. Solids, Suspended 34. Phosphorus. Total as P 53. Lead 71. TCLP-Metals 16. 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. L; 57. Molybdenum 75. TCLP-BNA’s -------- if--------- S 7 58. Nickel

NYC-WTC_000027497