Chain of custody record, Westchester County Department of Labs

NYC 9/11 Public Portal Document

UI 8 ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 bi^*^ UtertchWtor County

Time/Date Set:________________________________ (914)593-5575 f NYS-ELAPNo. 10108 fO Form A-70 (rev. 1/96) Sample Type (circle one): ). Potable . 3. Non-Potable Treated Bottle - fx_______ ■ 2. Non-Potable 4. Other_________ ;________________ . Chain of Custody? .yes no Time/Date Collected:,; _ Comments: Collected By: U wn tyi^aehcv Code: _ PWS #: ■ . Source ID:. Type Descriptor. Collected From: , , • / Blllib: ■ ‘ Location's/lndividual’s Name ^A/ • y ’■ _ ‘.' Name/Cdmpany .. »■

Street___________ _ _T; Street • City/St/Zip________ - L:' Citv/St/ZiD ' Identification of Source ‘ r- j_ ' Tphbrie#: Fax #:_ Collection Point I M |: CA, Ch, bp. Check#; /Amounts ' • :Y -- .iA: BACTERIOLOGICALAN^YSES;/ ORGANIC PpTABLE ANALYSES , ORGANIC NONPOTABLE/SOLID ANALYSES i : • iggisatjs Count (hemodialysis & all others) ■., 2. Coliform P/A'(public supplies) X*' >iSBi2iWg=;-S^S 3. Coliform MPN (priv well, raw, stp)’. <4’’T*.Total frihalomet^ane Potential (510)?;' 4, Fecal Coliform (all sarnplesj ' .5, Microextfactabies (504) u a- / , . ' 4, Phthalates (606/8060) ; 5, Organochlorine Pesticides (60^8080)' nt- 5, Microscopic ‘ . Pesticidesl507) .; . g " /.i'g'-r.f,'. 6, PCB ’s (Arochlors) (^8/8080) X' 6, Macroscopic Te^ade^^B screen (508) 7, Herbicides.(SM,18/664P;-8j51) . y 7. API //A: a^iPCB as D^chlOT6bipheriylj^8Aj'T^/^Y8, ''Other Pesticides (SM:'18/6630) ; A- g 8. Other: ______ 9/'Herbicide's7515)': T? g. Petroleum Hydrocarbon Scan (310-13) • L Refrigerated? ' yes no f-. •; Pesticides '(^5) > ...<\ 1O, Glycols in Water. A.: • A /'y. • VL Carba^te Pesticjdes (531) A: Yg. '; :. ‘11, Acid Extractables (625/8270) „ . . ' 12,Glyph^^ (547).f* g,: ; -AY ; .>..1A Base Neutral Extractables (625/8270) Chionnated?; .yes_____ no 13, Diquat’(549) A? aT ■ y ..'''.'.5. Q^GC/MS Unknown Scan ' T 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-1 8/6630) 16. Pesticides (DEF) Total Chlorine Res: mg/L 17. Petroleurri/Hydrocarbon Scan (310-13) 17. PCB's (Arochlors) (DEF)

pH, 5 INORGANIC ANALYSES REQUESTED - Lab#: I (circle tests) 1, Color 20. Acidity 39, Aluminum .. 59. Potassium 2. Turbidity 21. Alkalinity, as CaCOs 40, Antimoiiy 60. Selenium 3. pH 22. Bromide 41, Arsenic > 61. Silver , 4, Conductivity 23. Bromate/Chlorafe/Chlorite 42, Barium 62. Sodium 5. Corrosivity (temp: 6. BOD (5 day) 7. .Soluble BOD (5 day) 8. Carbonaceous BOD (5 day) 9. Chemical Oxygen Demand .’C) 24, Chloride . 25, Cyanide 26, Fluoride • =■

27, Hardness, Total as CaCOa 28, Nitrogen, Ammonia as N 43, Beryllium 44, Boron 45, Cadmium 46, Calcium, as CaCOa 47, Calcium, Ca”^ 63. Thallium 64. Vanadium 65. Zinc CLP 66. Metals/CN V; 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 •? Y? 14. Solids. Settleable 33. Phenol 52, Iron TCLP g; 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 . / i 56. Mercury .74. TCLP-Volatiles 19. Other:_______________ 38. l)V254 • ',.57. Molybdenum 75. TCLP-BNA’s . 4^68?Nickel ■

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