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 NYS-ELAP No. 10108 Pme/Date Set: _______________ _ Form A-70 (rev. 1/96) Sample Type (circle one): ;■ 664 - e 1) Potable 3. Non-Potable Treated Bottle #s_ 2. Non-Potable 4. Other____________ Chain of Custody?_____ yes no Time/Date Collected: LlJ (( 2.^2l2£iJ.__ __ (od Comments: — Collected By— Agency Code: PWS #_ Source ID: Type Descriptor: Collected From: Bill to: Location’s/Individual’s Name Name/Company. Street_________________ Street_____ __ City/SiZip_ ———=- Citv/SUZi Identification of Source ,.. ............. .... .......... .__Lep— Phone#: ..... .Fax #: Collection Point.................. ..... ................... CA, CH. B1? Check#:___ _ Amounts.

BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES - ORGANIC NONPOTABLE/SOLID ANALYSES Lab#: ...................... Lab #: ................ (circle tests) (circle tests) . ho ■. 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 (606/8060) 4. Fecal Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8080) 5. Microscopic 6. Pesticides (507) ‘As 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) (EAPI 1 V ___________ 9 Herbicides (515) (10. Pesticides (525) 9. Petroleum Hydrocarbon Scan (310-13) 10. Glycols in Water Refrigerated? .yes no 11. Carbamate Pesticides (531) 11. Acid Extractables (625/8270) 12. Glyphosate (547) 1,2 Base Neutral Extractables (625/8270); Chlorinated’’: yes no 13. Diquat (549) (13 GC/MS Unknown Scan " .*s 14. Chlorination Disinfection Byproducts (551) 14. Purgeable Halocarbons (DEF) Free Chlorine Res:. mg/L 15. Haloacetic Acids (552) . 15. Purgeable Aromatics (DEF) 16. Other Pesticides (SM-18/6630) 16. Pesticides (DEF) < Total Chlorine Res: r./—0m mg/L 17. Petroleum/Hydrocarbon Scan (310—1 17. PCB’s (Arochlors) (DEF) f pH _ 1___ ________ * 4+ INORGANIC ANALYSES REQUESTED - Lab#:. (circle tests) 2-64* Ml v G1 / 1. Color 20. Acidity 39. Aluminum 59. Potassium 2. Turbidity 21. Alkalinity, as CaCO3 40. Antimony.. 60. Selenium' 3. pH 22. Bromide 41. Arsenic* t 61. Silver : ' 4. Conductivity 23. Bromate/Chlorate/Chlorite 42. Barium? < 62. Sodium T 5. Corrosivity (temp: °C) 24. Chloride 43. Beryllium 63. Thallium 6. BOD (5 day) 7. Soluble BOD (5 day) ( 25. Cyanide 26. Fluoride 44. Boron 45. Cadmium 64. Vanadium 65. Zinc C 8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCO3 46. Calcium, as CaCOa CLP 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-volatiles 12. Total Organic Halides 31. Nitrogen, Total Kjeldahl as N 50. Cobalt 69. Pesticides/PCB’s JI 13 Solids, Percent (%) 32. Oil and Grease 51. Copper 70. Disk Deliverables 44 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 19. Other____ 38. IJV254 57. Molybdenum 75. TCLP-BNA’s 58. Nickel -rr "—"* —i NYC-WTC_000027892