Chain of custody record, Westchester County Department of Labs

NYC 9/11 Public Portal Document

111 ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 UtMichattar County (914)593-5^5" q. NYS-ELAP No. 10108 Time/Date Set:__________________ 7^ A-70Jrev. 1/96) Sample Type (circle one); J? Potable 3. Non-Potable Treated Bottle rs:_;________ L_—_________

2. Non-Potable 4. Other Chain of Custody? .yes .no Time/Date Collected: J__ Comments^____ Collected By: ■'Agency Code: -1- .PWS#;_L___ .Source ID:. Type Descriptor:, Collected From: ■ BUI to: - :•, '• Location’s/lndividuars Name 11 Name/Corhpany I'U Street__________ ■ Street_2^^_i_

Citv/St/Zip ■ ■ Crtv/SVZiP \ Phofi^: " Identification of Source_LL _Fax#:_ -■ ■

Collection PointA ca;ch?bi?,, . Check#:- 'Amounts ■ / - . ■ ■ ■■ 'Ir hS-iA? . NONPOTABLE^OLD A^LYSES

Count (hemodialysis’ki'll/bthere)^^ ,5z6ta1ileHa1^r8bns(524) -u-h—/ ’/??»<^^/;^' -- 2. ' Purgeable Aromatics (624/826d)W7n7-7^ • 2. Coliform P/A (pubiic'.-supplies)*'^^;? 7.vSlatiie7Vorriatics'(524)- 3. Acroleiri&Acrylbnitrile(624)'X-^>>^ ' 3. Coliform MPN (priv we'lL^aw.^tp) 1.'■?Total Trihajorpethane PoterjUal'(510)’ '. 4. Phthalates (6’06/8060) 4. Fecal Coliform (all samples)'f7 5. Microextractables (504) ''V. ' Organochlorine Pesticides (608/8080) A' 5. Microscopic . ■ Pesticides (507);-: - - I;-, < 6. PCB's.(Arochlors) (60878080) ; , 6. Macroscopic “ ' - .L-r/k.? ■' -5. ^7;Pesticiele8/PCB.^PBen-’(598)'^\»*' . 7. Herbicides (SM-18/6640’; ■8151)'.: ■8.'. PCB as Decachlorobiphenyl.(508A)' : 8. Other Pesticides (SM-18/6630) 8. Other: _______ •a*-Herbicides'(5i5) .' /• •'■Y-'" 9. Petroleum Hydrocarbori Scan (310-13) CJ Pesticides (525) .. .. . .. , 10. Glycols in Wafer : ... . ./L ;• Refrigerated? 11 .-^Carbarhate Pesticides (531) - ‘ 11. Acid Extractables (625/8270)- •12. Glyphosate (547) J2, Base Neutral Extractables (625/8270) :yes.no . 75/ ;,13. Diquat (549) . • ■ . ..,.i.a ; . 0,3/GC/MS Unknown Scan Chlorinated?: 14. Chlorination Disinfection Byproducts (551) 14. Purgeable Halocarbons (DEF) Free Chlorine Res: :i.mg/L T5. Haloacetic'Acids (552) 15. Purgeable Aromatics (DEF) .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) .

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INORGANIC ANALYSES REQUESiTED - Lab#:. cr? ■ (circle tests) . ' 1 1. Coior 20. Acidity. 39. Aluminum 59. Potassium j 2. Turbidity 21. Alkalinity, as CaCOa 40. Antimony 60. Selenium 1 ( 3- pH 22. Bromide 41. Arsenic 61. Silver 4. Conductivity ' 23. Bromate/Chlorate/Chlorite 42. Barium 62. Sodium I 5. Corrosivity (temp; .°C) 24. Chloride 43. Beryllium 63. Thallium 1 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 CaCOs 46. Calcium, as CaCOa CLP 9. Chemical,Oxygen Derhand 28. Nitrogen, Ammonia as N 47. Calcium, Ca*^ 66. Metals/CN 10. Dissolvedifcxygen 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 aslN 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 Y/i 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-Volatile's"; 9; 19. Other;_______________ 38. IIV254 57. Molybdenum 75. TCLP-BNA’s 58.'Nickel 7

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