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

NYC 9/11 Public Portal Document — * t/ 2 V < m 1

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM

III eme/Date Set: WESTCHESTER COUNTY LABORATORIES AND RESEARCH

--14)593-5575 * j ■ 2 Dana Road, Valhalla, New York 10595 NYS-ELAP No. 10108 Form A-70 (rev. 1/96)

Sample Type (circle one): 1. Potable 3. Non-Potable Treated Bottle #’s: 2. Non-Potable 4. Other , ........ ................... 12/2 Chain of Custody? .yes no

Time/Date Collected: -02/200/__ 4 MT! Comments: Collected By: 1 . PS (4(*S Agency Code:. PWS #:__________ Source ID:. Type Descriptor:

Collected From: Bill to: Location's/Individual's Name..... -. .................... ....... .. ... Name/Company Street ......... ..................................... ......................... . Street qd City/SVZip----------------------------------------------------------------- City/St/Zip’ Identification of Source__________________ __ Phone#:,. ..Fax #: Collection Point, 1 ................ .. _ 31141 CA, CH, Bl?• Check#:._____ Amounts

BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES

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) 3/ Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624) 2. Coliform P/A (public supplies) 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 : A Pesticides (507) 6. PCB’s (Arochlors) (608/8080) 6. Macroscopic . (Z) Pesticides/PCB screen (508) 1 ' . 7. Herbicides (SM-18/6640; 8151) AAPi 8. PCB as Decachlorobiphenyl (508A) n 8. J. Other ... •Pesticides JowoUl Si(SM-18/6630) ,UUU, a Other:._ 1_________ 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) 12. Glyphosate (547) 12. Base Neutral Extractables (625/8270) 13. Diquat (549) . (13. GC/MS Unknown Scan ■ Chlorinated?: s yes_____ no 14. Chlorination Disinfection Byproducts (551) 14. Purgeable Halocarbons (DEF) 15. Haloacetic Acids (552) 15. Purgeable Aromatics (DEF) - Free Chlorine Res: ma/L 16. Other Pesticides (SM-18/6630). 17. Petroteum/Hydrocarbon Scan (310-W 16. Pesticides (DEF) (Arochlors) Ts............... 17. PCB - (DEF) J Total Chlorine Res: mg/L .. - i:—J L * pH

INORGANIC ANALYSES REQUESTED - Lab#: AS— i ----------------------------------- ---------- ------------------------------------- —------ -------- - p

(circle tests) 1. Color— 20. Acidity 39. Aluminim 59. Potassium 2. Turbidity 21. Alkalinity, as CaCO3 40. Antimony- 60. Selenium 2 3PH 22. Bromide 41 . Arsenici", 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 CaCO3 46. Calcium, as CaCO3 CLP .4 - . 9. Chemical Oxygen Demand 28. Nitrogen, Ammonia as N ' 47. Calcium, Ca*2 ' ' 66. Metals/CN t-ses. * 10. Dissolved Oxygen 29. Nitrogen, Nitrate as N 48. Chromium, Total a S 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 13 Solids, Percent (%) 32. Oil and Grease 51. Copper 0 70. Disk Deliverables M. Solids, 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 38. IIV254 75. TCLP SNA’s ( 19. Other-__ _ ___________ 57. Molybdenum 58. Nickel

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