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

NYC 9/11 Public Portal Document

ITT । ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM "EMTNAe.ter WESTCHESTER COUNTY LABORATORIES AND RESEARCH OVCO1T 2 Dana Road, Valhalla, New York 10595 1 (914)593-5575 „ / _ — NYS-ELAP No. 10108 @eDate Set: » Form A-70 (rev. 1/96) -=m1 A -------------------------- *------ ample Type (circle one): *25, 27 7 7 ■ • 1. Potable 3. Non Potable Treated Bottle #‘s: ‘s0// 0 100//007/// _/7==4 ya/ad. 2. Non Potable 4. Other _ Chain of Custody? yes no Time/Date Collected:-....... 7/4_____020 Comments: Collected By: 2 f S— Agency Code:... , ...... ... PWS #: _______ Source ID: Type Descriptor: Collected From: ; , 4 " ' 4 P Bill to: Location’s/Individual’s Name / ‘ A Name/Company Street Street.................... City/St/Zip D0* City/St/Zip Identification of Source .. . Phone#:________ Fax#: Collection Point _ ^7'7^ 71176 CA.CH, Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/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) 3. Coliform MPN (priv well, raw, stp) 4. Total Trihalomethane Potential (510) 4. Phthalates (625/8270) i 4. Fecal Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8081) 5. Microscopic : 6. Pesticides (507) 6. PCB's (Arochlors) (608/8081) (D Pesticides/PCB screen (508) 7. Methoprene (616) 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPAI 978/8151) 9. Herbicides (515) 9. Pesticides (SM18/6630) (o. Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13) Refrigerated? yes o H. Carbamate Pesticides (531) 11. Glycols Chlorinated:? yes _ no 12. Glyphosate (547) 12. Acid Extractables (625/8270) 13. Diquat (549) 13, Base Neutral Extractables (625/8270) Free Chlorine Res:. mg/L 14. Chlorination Disinfection Byproducts (551) " ‘) GC/MS Semivolatile Unknown Scan Total Chlorine Res: -... mg/L 15.Haloacetic Acids (552) 2 . Purgeable Halocarbons (DEF) 16. Pesticides (SM 18/6630) Purgeable Aromatics (DEF) pH _____________ I 17. Petroleum/Hudmcarhon - Pesticides/PCB’s (DEF) nJ - . 18. Other . Other: ____________ __ . e — -------— ------- - . 1 ---- "... . wnouonntn INORGANIC ANALYSIS REQUESTED - Lab*: -> (circle tests) 1. Color . : .J 20. Acidity 39. 59. Potassium 2. Turbidity " 21. Alkalinity, as CaCOa 40. Antimony 60. Selenium 3. pH - " 22. Bromide 41. Arsenic 61. Silver i 4. Conductivity 23. Bromate/Chlorate/Chlorite 42. Barium 62. Sodium 5. Corrosivity (temp:. °C) 24. Chloride 25. Cyanide 43. Beryllium 44. Boron 63. Thallium 64. Vanadium 6. BOD (5 day) 26. Fluoride 45. Cadmium 7. Soluble BOD (5 day) 8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOa 46. Calcium, as CaCOa CLP---------- 65. Zinc

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 Solids, Settleable 33. Phenol ■ ; 52. Iron ’ 1 34. Phosphorus Total as P 53.Lead TCLP Solids, Suspended 71.TCLP-Metals 16. Solids. Total 35. Phosphorus, Ortho as P 54 Magnesium 36. Sulfates 55 Manganese 72.TCLP-Pesticides 17. Solids, Total Dissolved 73. TCLP-Herbicides 18. Solids, Total Volatile 37. Surfactants 56. Mercury 74. TCLP-Volatiles 19. Other: __________ 38. UV254 57 Molybdenum 75. TCLP-BNAs 58. Nickel

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NYC-WTC_000027889