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 MS ' (914)593-5575 . NYS-ELAP No. 10108 wme/Date Set: Form A-70 (rev. 1/96)

Sample Type (circle one): 1.17 41, 1 , 1c 1. Potable 3. Non-Potable Treated Bottle #s:-1.. «. *. 11. —. A 2. Non-Potable 4. Other_________ _____ Chain of Custody? .. yes no Time/Date Collected: ) Ws . Comments: . ," Collected By: 3 * AAO Agency Code: PWS #: Source ID: Type Descriptor:. Collected From: Bill to: Location's/Individual's Name_Ry Name/Company. Street ta Street City/StZip Citv/SVZip Identification of Source................ —..... . Phone#:, Fax #: Collection Point P . 5 2 CA, CH, BI?_ Check#: Amounts.

BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES Lab#:............... .......... ............... .... tab #_ (circle tests) (circle tests) 1. Heterotrophic Plate 1. Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260) 2.) Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260) Count (hemodialysis & all others) 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) / 8. PCB as Decachlorobiphenyl (508A) . 8. Other Pesticides (SM-18/6630) / MAPI + "Brother:.

Refrigerated? ......... yes nos " 9. Herbicides (515) 10 Pesticides (525) 11. Carbamate Pesticides (531) . ?o.Zs$cJs-mWzaspcasbonScant310-13) 11. Acid Extractables (625/8270) / 12. Glyphosate (547) 12. Base Neutral Extractables (625/8270) Chionnated'’: yes no - - 13. Diquat (549) . *‘ IS Unknown Scan / 4"

r- 14. Chlorination Disinfection Byproducts (551) TA Purgeable Halocarbons (DEF) Free Chlorine Res:. mg/L 15. Haloacetic A 5 La------ — Acids (552) . . 15. Purgeable Aromatics (DEF) 16. Other Pestici. ides (SM-18/6(530) . 16. Pesticides (DEF) Total Chlorine Res: 17. Petroleum/Hyrdrocarbon Scan (310-13); |||| 17. PCB’s (Arochlors) (DEF) (

pH i met i »=== —------ _ - ________ . | .Ai i l ■ _____________ --------------------------------- - -------------- —— T* 1 —- --------- INORGANIC ANALYSES REQUESTED - Lab#:. - ; • 2191 7."Y. W L sue

1 (circle tests) $ : —us 1. Color 20. Acidity 39. Aluminu 59. Potassium 2. Turbidity 21. Alkalinity, as CaCO3 40. Antimon, 41.Ar^ni4' 60. Selenium 3. pH ' 22. Bromide 61. Silver — 4. Conductivity 5. Corrosivity (temp: ,.1..... °C) 6. BOD (5 day) 23. Bromate/Chlorate/Chlorite 24. Chloride 25. Cyanide 42. Barium. 43. Beryllium 44. Boron 62. Sodium 63. Thallium 64. Vanadium C 7. Soluble BOD (5 day) . . 26. Fluoride 45. Cadmium 65. Zinc —8 Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOa 46. Calcium, as CaCO3 CLP 9. Chemical Oxygen Demand 28. Nitrogen, Ammonia as N 47. Calcium, C?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-volatiles 12. Total Organic Halides 31. Nitrogen, Total Kjeldahl as N 50. Cobalt 69. Pesticides/PCB’s 403 Solids, Percent (%) 32. Oil and Grease 51. Copper 70. Disk Deliverables ' w Solids, Settleable 33. Phenol 52. Iron TCLP 15. Solids. Suspended 34. Phosphorus. Total as P '■'S3. 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 / . ' 57. Molybdenum 75. TCLP-BNA's — 58. Nickel

NYC-WTC_000027888