Chain of custody record, Westchester County Department of Labs

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM »m WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalia. New York 10595 (914) 593-5575 NYS-ELAP No. 10108 Time/Date Set: Form A-70 (rev.1/96)

SampleType (circleone): 3. Non Potable Ttsated Bottle #"0: C-<—______ 2. Non Potable <4. Other__________ Chain of Custody? yes no Time/Date Collected: Comments: Collected By;3L. RkbavvAo Agency Code: PWS#:_______ Source ID: .Type Descriptor: Collected From: Bill to: Location’s/lndividuars Name fe Vov\X Name/Company Street__________________ Street______ _ City/St/Zip ... ............. Clty/St/Zlp____ Identiflcatidn of Source . Phone#: , , . Fax#: Collection Point \ Check#:

ORGANIC POTABLE ANALYSIS ’ •r la h#: tests) (circle U I1 (circle ‘ ’.Xy?"' 1. Heterotrophic Plat? Y’ ' V Trihalomethanes (524) 1. Purgeable Halocarbons (624/8?60) Count (hernodialysls all others) A2.]Volatlle Halocarbons (524) 2. Purgeable Aromatics (624/8260) 2. Coliform P/A (puWic suppIles) ^Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624) 3. Coliform MPN (priv well, taw, stp) 4*TotalTrihalomethanePotential (510) 4. Phthalates (625/8270) 4. Fecal Coliform (aD samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8081)' ' 5. Microscopic ’' 4 & Pesticides (507) 6. PCB’s (Arochlors) (608/8081) ; 6. Macroscopic © Pesticides/PCB screen (508) 7. Methoprene (616) ' * 7. API 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPAI978«151) 8. Other. Herbicides (515) 9. Pesticides (SM18/6630) ;; IPesticides (525) 10. Petroleum Hydrocarbon Scan (310-13) Refrigerated? yes no TT ICarbamate Pesticides (531) 11. Glycols- Chlorinated:? yes.__ no 12. Glyphosate (547) 12. Acid Extractables (625/8270) 13. Diquat (549) ISL^Base Neutral Extractables (625/8270) ’ Free Chlorine Res:. _______ mg/L 14. Chlorination Disinfection Byproducts (551) fl4^C/MS Semivolatile Unknown Scan 15. Haloacetic Adds (552) iSTPurgeable Halocarbons (DEF) Total Chlorine Res: _______ mg/L 16. Pesticides (SM18/6630) __ - 16. Purgeable Aromatics (DEF) pH 17. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticidos/PCB’s (DEF) 1 18. Other______________ _________ 18. Other:_______________ ________

INORGANIC ANALYSIS REQUESTED - Lab#: (circle tests) 1. Color 20. Aridity 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. BromateZChlorate/Chlorite 42. Barium 62. Sodiupi 5. Corrosivity (temp: .“C) 24. Chloride 43. Beryllium 63.Thallium . 6. BOD (5 day) 25. Cyanide 44. Boron 64. Vanadium! U { 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-violatiles 12. Total Organic Halides 31. Nitrogen, Total Kjeldahl as N 50.Cobalt 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 54 Magnesium 71 .TCLP-Metals 16. Solids, Total 35. Phosphorus, Ortho as P 72.TCLP-Pesticides 17. Solids, Total Dissolved 36. Sulfates 55 Manganese 73.TCLP-Herbicides 18. Solids, Total Volatile 37. Surfactants 56. Mercury 57 Mdybdauim 74. TCLP-Volatiles 19. Other________________ 38. UV254 58. Nickel 75.TCLP-BNA’s

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