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Chain of custody form, Westchester County Dept of Labs, Oct

Machine-extracted title · confidence 95%

Chain of custody record for samples submitted to the Westchester County Department of Labs and Research.

NYC-WTC_000027804–000027811

Folder label: “24944

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NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ster WESTCHESTER COUNTY LABORATORIES AND RESEARCH iv.com 2 Dana Road, Valhalla, New York 10595 (914) 593-5575 NYS-ELAPNo. 10108 TDate Set: X 9m A-70 (rev.1/96) Sample Type (circle one): /SS0 ----- 6w—49 Q.. E2 ----_. 79.. fry 1. Potable 3. Non Potable Treated Bottle #s:. eass , os8 o Chain of Custody?__ I yes | no ~3 2. Non Potable 4. Other Time/Date Collected: / Poj U : / P* Comments: Collected By. v s Vos 6 - -V Agency Code: PWS#:______ Source ID: .Type Descriptor: Collected From: Bill to: Location’s/Individual’s Name 2v Name/Company Street________________ Street_______ City/St/Zip_____________ CIty/St/Zip____ Identification of Source___1 Phone#: Fax#: Collection Point 5550 De# CA,CH, Bl? 2Z Check#: Amounts. -2/00% 5ey BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPQTABLE/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) 8 3. Coliform MPN (priv well, raw, stp) 4. Total Trihalomethane Potential .(510) 4. Phthalates (625/8270) — 4. Fecal Coliform (ail samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/808183 5. Microscopic 6. Pesticides (507) 6. PCB’s (Arochlors) (608/8081) 1 6.@groscopic ( Pesticides/PCB screen (508) 7. Methoprene (616) P 7.77 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151) 8. Other__________________ 9 Herbicides (515) 9. Pesticides (SM18/6630) > (0 Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13) Refrigerated? yes no 11. Carbamate Pesticides (531) 11. Glycols Chlorinated:? yes no 12. Glyphosate (547) 12. Acid Extractables (625/8270) CD J 13. Diquat (549) 13. Base Neutral Extractables (625/8270) Free Chlorine Res:. mg/L 14. Chlorination Disinfection Byproducts (551) (4.GC/MS Semivolatile Unknown Scan 15. Haloacetic Acids (552) 15. Purgeable Halocarbons (DEF) 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:. *1 8. Other: -

INORGANIC ANALYSIS REQUESTED - Lab#: (circle tests) 14 4 C CO 1. Color 20. Acidity 39. Aluminum slum -< 2. Turbidity 21. Alkalinity, as CaCOs 40. Antimony 60. Selenium 3. pH 4. Conductivity 5. Corrosivity (temp:__ 6. BOD (5 day) ' 7. Soluble BOD (5 day) °C) 22. Bromide 23. Bromate/Chlorate/Chlorite 24. Chloride 25. Cyanide 26. Fluoride 41. Arsenic 42. Barium 43. Beryllium 44. Boron 45. Cadmium 61. Silver 62. Sodium 63. Thallium 64. Vanadium 65. Zine 1 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*2 66. Metals/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 Colids, Settleable 33. Phenol 52. Iron 15. Solids, Suspended 34. Phosphorus Total as P 53.Lead TCLP 54 Magnesium 71 .TCLP-Metals 35. Phosphorus, Ortho as P 16. Solids, Total 36. Sulfates 55 Manganese 72. TCLP-Pesticides 17. Solids, Total Dissolved 73.TCLP-Herbicides 18. Solids, Total Volatile 37. Surfactants 56. Mercury 19. Other: ________________ 38. UV254 57 Molyodenum 74. TCLP-Volatiles 75.TCLP-BNA’S 58. Nickel

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NYC-WTC_000027808Source: NYC Law Department, mirrored locally

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NYC-WTC_000026432 · Box DEP Box 19

Record documenting sample transfer and custody for environmental testing at the Westchester County Department of Labs & Research.

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