Chain of custody record, Westchester County Department of Labs

NYC 9/11 Public Portal Document

HI ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road. Valhalla. New York 10595 UlMlchMtor County ,9.4,593.5575 , NYS-ELAP No. 10108 Time/Date Set:_______________________ Form A-70 (rev. 1/96) Sample Typo (circle one): , V<z ,fc- V 1. Potable 3. Non-Potable Treated Bottle #'s: F or .< -Q,... / 2. Non-Potable 4. Other Chairuof Custody?yes no ’ Time/Date Collected: Il / Comments; Collected By: Agency Code: PWS #;________ Source ID; Type Descriptor:. Collected From: Bill to; Location's/lndividual’s Name. Name/Company.

f Street __________ Street_______ __ City/St/Zip City/St/Zip Identification of Source AX Phone#: _________ Fax ■ Collection Point. I CA.CH. Bl? Check#: Amounts.

/BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES ;Lab#/ ■ Lab #;■ ,(circletests) . • •• f TWr-- (circle tests) ■ 1. Heterotrophic Plate ., ' 1. Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260) V Count (hemodialysis & all others) 2. Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260) :j;2. Coliform P/A (pubfic 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)

I - 5. Microscopic -6. Macroscopic '.7. API 8. Other:___________ ■ ‘ ■ 6. Pesticides (507) Pesticides/PCB screen (508) 8. PCB as Decachlorobiphenyl (508A) ^Herbicides (515) Pesticides (525) 6. PCB’s (Arochlors) (608/8080) 7. Herbicides (SM-18/6640; 8151) 8. Other Pesticides (SM-18/6630) 9. Petroleum Hydrocarbon Scan (310-13) 10. Glycols in Water : Refrigerated? Yes. .no' n. Carbamate Pesticides (531) 11. Acid Extractables (625/8270) 12. Glyphosate (547) Base Neutral Extractables (625/8270) Chiorinated?;

Free Chlorine Res:. .yes. .no

mg/L 13. Diquat (549) 14. Chlorination Disinfection Byproducts (551) 15. Haloacetic Acids (552) § GC/MS Unknown Scan Purgeable Halocarbons (DEF| 15. Purgeable Aromatics (DEF) y-.- 16. Other Pesticides (SM-18/6630) 16. Pesticides (DEF) Total Chlorine Res; mg/L 17. Petroleum/Hydrocarbon Scan (310-13) 17. PCB’s (Arochlors) (DEF) y .1 pH

INORGANIC ANALYSES REQUESTED - Lab#:. (circle tests) 1. Color 20. Acidity 39. Aluminum 59. Potassium 2. Turbidity 21. Alkalinity, as CaCOs 40. Antimony 60. Selenium 3.. P.H 22. Bromide 41. Arsenic 61. Silver 4.' Gpnductivity 23. Bromate/Chlorate/Chlorite 42. Barium 62. Sodium i 5. Cdrrosivity (temp; .°C) 24. Chloride 43. Beryllium > 63. Thallium ■ 6. B.OD (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 CaCOs 46. Calcium, as CaCOs CLP 9. Chemical Oxygen Demand 28. Nitrogen, Ammonia as N 47. Calcium, Ca*’ 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 13. Solids, Percent (%) 32. Oil and Grease 51. Copper 70. Disk Deliverables 14. 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. UV254 57. Molybdenum 75. TCLP-BNA’s 58. Nickel

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