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

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. ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 — . (914) 593-5575 ■ _ m ? NYS-ELAP No. 10108 (n e/Date Set: Form A-70 (rev. 1/96)

1 1 4 zt - Sample Type (circle one): 1. Potable :3. Non Potable Treated Bottle #‘s: 1- ——------------------ 2. Non Potable 4. Other _ Chain of Custody? ___ yes _ no : — Time/Date Collected: —------------ _ Comments: — Collected By: 2. N ‘ n Agency Code: PWS#: _ Source ID: Type Descriptor: Collected From: Bill to: Location’s/Individual’s Name KQs Name/Company Street _____ ___________ Street _ — City/SUZip______________ City/St/Zip' Identification of Source — : Phone#: _ Fax#: Collection Point • x3 CA.CH, Bl? . Check#: Amounts.

BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS Lab#: - r 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 , / 6. Pesticides (507) 6. PCB's (Arochlors) (608/8081) ^Macroscopic (7 Pesticides/PCB screen (508) 7. Methoprene (616) WPI 8. Other: _ 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151) 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. Add Extractables (625/8270) 13. Diquat (549) . Base Neutral Extractables (625/8270) Free Chlorine Res: mg/L 14. Chlorination Disinfection Byproducts (551) (4/GC/MS Semivolatile Unknown Scan Total Chlorine Res: _ mg/L 15. Haloacetic Acids (552) 15. Purgeable Halocarbons (DEF) 16. Pesticides (SM18/6630) 16. Purgeable Aromatics (DEF) pH 17. PetroleunVHydrocarbon Scan (310-13) 17. Pesticides/PCB’s (DEF) 18. Other:18. Other: , . — - = INORCANIC ANALYSIS REQUESTED - Lab#: 2537 ■v .UJAS * 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 C 4. Conductivity 23. Bromate/Chlorate/Chlorite 42. Barium 62. Sodium 5 - 5. Corrosivity (temp:. °C) 24. Chloride 25. Cyanide 43. Beryllium 44. Boron 63. Thallium 6. BOD (5 day) 64. Vanadium 7. Soluble BOD (5 day) 26. Fluoride 45. Cadmium 65. Zinc 27. Hardness, Total as CaCO3 46. Calcium, as CaCOs 5 8. Carbonaceous BOD (5 day) CLP vakooiowi / ; 9. Chemical Oxygen Demand 28. Nitrogen, Ammonia as N 47.Calcium, Ca+2 66. Metals/CN 10. Dissolved Oxygen 11. Total Organic Carbon 29. Nitrogen, Nitrate as N 30. Nitrogen, Nitrite as N 48. Chromium, Total 49. Chromium, Hexavalent 67. Volatiles 68. Semi-violatiles s 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. f Solids, Settleable 33. Phenol 52. Iron 5 Solids, Suspended 34. Phosphorus Total as P 53.Lead TCLP 71 TCLP-Metals 16. Solids, Total 35. Phosphorus, Ortho as P : 54 Magnesium 72.TCLP-Pesticldes 17. Solids, Total Dissolved : 36. Sulfates 55 Manganese / 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 "s ----- *== 7 . ........*.............■■■ ran . - _ -—............... -—- - NYC-WTC_000027887