Chain of custody record, Westchester County Department of Labs

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914) 693-5575 NYS-ELAP No. 10108 Time/Date Set Form A-70 (rev.1/96)

Sample Type (circle one): BjillpRIIBg 3. Non Potable Treated Bottio #'s: gS‘lX'5 ■ \ , ^3^_________ • 2. Non Potable mother__________ Chain of Custody? yes no Time/Date Collected: Comments: —I------------------------------------------

Collected By: si» R \botn Ao Agency Code: PWS#:_______ Source ID: .Type Descriptor,^ Collected From: Bill to: Location’s/lndlvlduars Name _ VSvors K Name/Company _ Street________ - Street________ CItv/StZZto Ctty/St/Zlp identification of Source____ _ Phone#: Fax#:

a CollectionPoint_32_-^S_ ■‘..c M CA.Cli Kt Check#:

bacteriological ANALYSIS Lab#: __ __________________ _ ORGANIC POTABLE ANALYSIS ‘Ste tests) b ^2-— ORGANIC NONPOTABLE/SOUP ANALY^I^I - ■ ■' '.'-'Y I (circle tests) 1. Trihalomethanes (524) 1. PurgeaBle Halocarbons (624/8260) '

I 1. Heterotrophic Plate Count (hemodialysis & all others) 2. Purgeable Aromatics^ (624/8260) 2. Coliform P/A (public supplies) V^Volatlle Aromatics (524) 3. Acrolein & Acrylonitrile (624) 3. Coliform MPN (priv well, raw, stp) 4. Total Trihalomethane Potential (510) 4. Phthalates (625/8270) 4. Fecal Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8081) 5. Microscopic 6. Pesticides (507) 6. PCB’s (Arochlors) (608/808n- - 6. Macroscopic /f?pesticides/PCB screen (508) 7. Methoprene (616) X 7. API eTPCB as Decachlorobiphenyl (508A) 8. Herbicides (EPAI978/8151) 8. Other_________________ _ 9. Herbicides (515) 9. Pesticides (SMI8/6630) (^Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13) Refrigerated? yes no TT Carbamate Pesticides (531) 11. Glycols Chlorinated:? yes no 12. Glyphosate (547) 12. Acid Extractabies (625/8270) 13. Diquat (549) 13. Base Neutral Extractabies (625/8270) Free Chlorine Res:- mg/L 14. Chlorination Disinfection Byproducts (551) (55)GC/MS Semivolatile Unknown Scan Total Chlorine Res: mg/L 15. Haloacetic Acids (552) 15. Purgeable Halocarbons (DEF) 16. Pesticides (SM18/e630) 16. Purgeable Aromatics (DEF) pH 17. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB's (DEF) / 18. Other_______ ________________ 18. Other_________ ’ . ,

INORGANIC ANALYSIS REQUESTED - Lab#: (circle tests) 1. Color 20. Acidity 39. Aluminum 59. Potassium 2. Turbidity 21. Alkalinity, as CaCOs 40. Antimony 60. Selenium 3. pH 22. Bromide 41. Arsenic 61. Silver 4. Conductivity 23. BromateZChlorateZChlorite 42. Barium 62. Sodium 5. Corrosivity (temp:__ .“C) 24. Chloride 43.Beryliium 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 ■gLP 9. Chemical Oxygen Demand 28. Nitrogen, Ammonia as N 47.Calcium, Ca*2 66. Metals/CN 10. Dissolved Oj^gen 29. Nitrogen, Nitrate as N 48. Chromium, Total 67. Volatiles 11. Total Organic Carbon 30. Nitrogen, Nitrite as N 49. Chromium, Hexavalent 68. Semi-violatiles 12. Total Organic Halides 31. Nitrogen, Total Kjeldahl as N 50.Cobait 69.Pesticides/PCB's 13. Solids, Percent (%) 32. Oil an 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________ 21______ 38. UV254 57 Mo^bdaraoh 58. Nickel . 75.TCLP-BNA5 :jaww«

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