Chain of custody record, Westchester County Department of Labs

NYC 9/11 Public Portal Document Xi

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM

UtelSlUlLy WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road. Valhalla, New York 10595 (914) 593-5575 NYS-ELAP No. 10108 Time^ate Set_________ Form A-70 (rev. W) San^le Type (circle one): 1. Potable 3. Non-Potable Treated Bottle #’sj___ •' Chainof^^stody? 2. Non-Potable 4. Other_____________ .yes .no Time/Date Collected: - Commoht8: Collecte<iBy:_________________ .Agency Code:. PWS .Source ID:. .Type Descriptor:__ 1 Collected R|bm: Bill to: Location's/lndividuars Name _ Name/Company •' '■ Street_______________________ Street - ■ ' City/SVZip___________________ . Citv/St/ZlD _______ _______________ Identification of Source_________ - ■ Phone#:, •■ • ; _Fax#: ■ ’ H • • _. I CA, CH, Bl?- " Check^- Amounts Collection Point V z * ■ \........... .• • '-.I . A:'/;

BACTERIOLOGICAL ANALYSES Lab#:____________________ (ctrcte tests). Purge^d ®ocarb<ih4;(524/8266y- :~^ 1. Heterotrophic Plate Count (hemodialysis & all others) Volatile Halocarbons (524) ■ ib Y t ' 2.' Purgeable Aromatics (624/8260) 2. Coliform P/A (public supplies) Volatile Aromatics (524) ; . . < - ' ’ Acrofeih & Aciylonitrite (624) 3. Coliform MPN (priv well, raw, stp) V Total Trihalometharie Potential (510) 4. PhthSUtes (606/80^ ‘ 4. Fecal Coliform (all samples) 5. Microextractables (504) . 5. zOrgahochlorinaJ^esticidos (608/8080) : 5. Microscopic *"^’6. Pesticides (507) e. PCB’s (Arochlorsj(608/8080) 6. Macroscopic @ Pesticide8«»CB screen (508) . . 7. Herbicidos (SM-18/6640; 8151) Y 7- AP! A 8. PCB as Decachlorobiphenyl (508A} ;. 8., OtAefPesticides (SM>18?6 8. Other:_\_______________ 9. Herbicides (515) 9. Petroleum Hydrocarbdn'Sca'n (310-13) Pesticides (525) lO.QIycoJsin Water / . Refrigerated? yes no 11. Carbamate Pesticides (531) - - 11. Acid Extractables (625/8270) . .. 12. Glyphosate (547) 12. Base Neutral Extractables (625/8270) Chlonnated?: .yes no 13. Diquat (549) ^^GC/MS Unknown Scan tr . ' 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: .mg/L 17. Petroleum/Hydrocarbon Scan (310-13) 17. PCB’s (Arochlors) (DEF) jj

pH

INORGANIC ANALYSES REQUESTED - Lab#:. (circle tests) 1. Color 20. Acidity 39. Aluminum 59. Potassium 2. Turbidity 21. Alkalinity, as CaCOa 40. Antimony 60. Selenium 3. pH 22. Bromide 41. Arsenic 61. Silver 4. Conductivity 23. Bromate/Chlorate/Chlorite 42. Barium 62. Sodium 5. Corrosivity (temp: .’C) 24. Chloride 43. Beryllium 63. Thallium 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 CaCOs CLP 9. Chemical Oxygen Demand 28. Nitrogen. Ammonia as N 47. im,Ca*’ 66. MetalsZCN 10. Di^oived Oxygen 29. Nitrogen, Nitrate as N 48,1 ^um. Total 67. Volatiles 11. TotaTOrganic Carbon 30. Nitrogen, Nitrite as N Hum, Hexavalent 68. Semi-volatiles 12. totarOrganifrHalides 31. Nitrogen, Total Kjeldahl as N 69. Pesticides/PCB's 13. Solids, Percent (%) 32. Oil and Grease 70. Disk Deliverables 14. Solids. Settleable 33. Phenol 52yrr6n ISLE 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. IIV254 57. Molybdenum 75. TCLP-BNA's SajJickei I

NYC-WTC_000070361