Chain of custody record, Westchester County Department of Labs

NYC 9/11 Public Portal Document I

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM A.com WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914) 593-5575 NYS-ELAP No. 10108 Time/Date Set: Form A-70 (rev.1/98) '

ng Sample Type (circle one);

2. Non Potable 3. Non Potable Treatad 4. Other___________ Bottle A

Chain of Custody?___ yes S' ,

no ■nme/Date Collected: Comments:___________________________________ ■ • Collected By:'^ Agency Code: PWS#:______ Source ID: Type Descriptor: ,^ Collected From: ry Bill to: Location’a/lndividual’sName QTo X Name/Company Street__________________ ______________ Street __ ____ City/SWOp____________________________ C(ty/St/Ztp wU Identification of Source . __ 4 ; Phone#-^^ Fax#: Collection Point 4' 'CA^^ Check#;

BACTERIOLOGICAL ANALYSIS : ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOUDJOL St’S Lab#:____________ Lab#: ■

(circle tests) (circletests) ~ I 1. Heterotrophic Plate 1. Trihatomethanes (524) • 1. Purgeable Halocarbons (624/8^) Count (hemodialysis & ail others) (^^Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260) 2. Coliform P/A (public supplies) i,3^olatile Aromatics (524) 3. Acrolein & Aciylonitrito (624) 3. Coliform MPN (priv well, raw, stp) 4. Total Trihalomethane Potential (510) 4. Phthalates (625/8270) 4. Fecal Coliform (aO samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8081) 5. Ml 6. Pesticides (507) 6. PCB’s (Arochlors) (608/8081) 6. lie (jz' Pestlcldes/PCB screen (508) 7. Methoprene (616) 7. API 8. PCB 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 Extractables (625/8270) 13. Diquat (549) 13. Base Neutral Extractables (625/8270) Free Chlorine Res:. _______ mg/L 14. Chlorination Disinfection Byproducts (551) T^C/MS Semivolatile Unknown Scan <-2.

Total Chlorine Res: _______ mg/L 15. Haloacetic Acids'(552) TK Purgeable Halocarbons (DEF) 16. Pesticides (SMi8/6630) " 16. Purgeable Aromatics (DEF) pH 17. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticidos/PCB’s (DEF) 18. Other_______________________ 18. Other_____________ __________

INORGANIC ANALYSIS REQUESTED - Lab#: (circle tests) V-Xe *i> 1. Color 20. Acidity 39. Aluminum 59. Potassium 2. Tuibidity 21. Alkalinity, as CaCOs 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 CaCOa CLP 9. Chemical Oxygen Demand 28. Nitrogen, Ammonia as N 47.Calcium, Ca*® 66. Metais/CN 10. Dissolved Ot^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.Cobalt 69.Pesticides/PCB’8 13. Solids, Percent (%) 32. Oil an Grease 51. Copper 70. Disk Deliverables 14. Solids, Settleable 33. Phenol 52. Iron 34. Phosphorus Total as P 53.Lead TCLP 15. Solids, Suspended 71 TCLP-Metals 16. Solids, Total 35. Phosphorus, Ortho as P 54 Magnesium 72.TCLP-Posticidos 17. Solids, Total Dissolved 36. Sulfates 55 Manganese 73.TCLP-Herbicide8 18. Solids, Total Volatile 37. Surfactants 56. Mercury 74. TCLP-Volatiles 19. Other.________________ 38. UV254 57 MolybdiWTum 75.TCLFBN/te <4 58. Nickel T**. .U. NYC-WTC_000070455