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

NYC 9/11 Public Portal Document " I - *4"" ***4 T ‘* " *

Ue+s ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ( besteum WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914) 593-5575 *%* X. Gime/Date Set: ; 4. a 7™ NYS-ELAP No. 10108 Form A-70 (rev. 1/96) bdii Sample Type (circle one): .. 27 *" ■■

7157 . 1. Potable 3. Non Potable Treated F Bottle #‘s: 717 77) 2. Non Potable 4. Other ___ J_________ Custody?yes no Time/Date Collected: /—/1H_ Collected By: Agency Code: af Source ID: Type Descriptor: Collected From: Bill to: Location’s/lndividual’s Name Ai * Name/Company Street _ Street City/StZip City/StZip Identification of Source . -_PUAa. muont "‘Lak!.’ - -.... D&0# 1 . .• 1 1 Phone#: _ Fax#: Collection Point )7C) 2/2 03 CA,CH, Bl? /Check#: Amounts.

BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS Lab#:------------------------- ------ ----------- Lab#: .) . (circle tests) -de (circle tests) . - 1. Heterotrophic Plate 5 1. Trihalomethanes (524) . 1 1. Purgeable Halocarbons (624/8260) Count (hemodialysis & all others) 2. Volatile Halocarbons (524) ' . Purgeable Aromatics (624/8260) 2. Coliform P/A (public supplies) 3. Volatile Aromatics (524) : rolein & Acrylonitrile (624) 3. Coliform MPN (priv well, raw, stp) 4. Total Trihalomethane Potential (510) - ^."Phthalates (625/8270) 4. Fecal Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8081) 5. Microscopic ■ 6. Pesticides (507) 6.7PCB‘s (Arochlors) (608/8081) AMacroscopic (7) Pesticides/PCB screen (508) 7. Methoprene (616) MPI 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151) 8. Other: _ 9. Herbicides (515) 9. Pesticides (SM18/6630) (10 Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13) Refrigerated? vesno 11. Carbamate Pesticides (531) 11. Glycols Chlorinated:? yes no 12. Glyphosate (547) J 2. Acid Extractables (625/8270) 13. Diquat (549) 3. Base Neutral Extractables (625/8270) Free Chlorine Res; mg/L 14. Chlorination Disinfection Byproducts (551) ( ^GC/MS Semivolatile Unknown Scan o Total Chlorine Res: mg/L 15. Haloacetic Acids (552) 5. Purgeable Halocarbons (DEF) Fs 16. Pesticides (SM18/6630) 16. Purgeable Aromatics (DEF) % pH_____________ ■

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INORGANIC: ANALYSIS REQUESTED- 2S41- ( (circle tests). 1. Color '■ 20. Acidity 39. Aluminum 59. Potassium 2. Tur w. 21. Alkalinity, as CaCOa 40. Antimony 60. Selenium 3. pH. 22. Bromide 41. Arsenic 61. Silver 4. Coi 23. Bromate/Chlorate/Chlorite 42. Barium 62. Sodium 5. Corrosivity (temp:__ °C) 24. Chloride ", K43. Beryllium 63. Thallium 6. BOD Oy)' 25. Cyanide MA Boron 64. Vanadium 26. Fluoride 716. Cadmium 7. Soluble BOD (5 day) 65. Zinc 27. Hardness, Total as Ca Re. Calcium, as CaCOa 7, 8. Carbonaceous BOD (5 day) 9. Chemical Oxygen Demand 28. Nitrogen, Ammonia at r 47. Calcium, Ca+2 66.Metals/CN 10. Dissolved Oxygen 29. Nitrogen, Nitrate as N 3 48. Chromium. Total w 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 (h Solids, Settleable 33. Phenol 52 . Iron • ? \ . 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-Pesticides 17. Solids, Total Dissolved 36. Sulfates 55 Manganese 73.TCLP-Herbicides 18. Solids, Total Volatile 37. Surfactants 56. Mercury 19. Other:• 38. UV254 57 Molybdenum 74. TCLP-Volatiles 58. Nickel 75.TCLP-BNAs

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