Chain of custody record, Westchester County Department of Labs

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM Z"

lb I WESTCHESTER COUNTY LABORATORIES AND RESEARCH f@).,. ■ Utestchesteftoorty 2 Dana Road, Valhalla, New York 10595 /. - Z NYS-ELAP No, ,0,08 I “Tima/DafeA?!). ;__ c ______ '___ _________ -c,_____ F££n? A-70/rev. 1/96) ~ - ■ sample Type (circle one): . E - 1, Potable 3. Non-Potabie Treked Bottle #’s.'i■ ■■OBIilBi 2 Non-Potable 4. Other„__L_______ ___________________ .. Chain of Custody? yes no Colleced:_____ _ ’ C ZZlAZ. r- Comments: Ooltected Ry: -■! - AE..V______ Agency Code: PWS #:; Source ID: ..Type Descriptor; CollecMRom: , y BliSto: ’ gcat'on's/lndividuai’s Name __ „ L -..... '. LZ: Name/Company_____ _

a.............. ....... Street_ _____ _____ ___

___ :_2. _______________ Cif .. ... I identification of Source, Phone#; ' Fax #:_ __ _ ___ f'oliection Point— SeIS JCA, CH, BP ; Check#: Amounts

^TERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES

abti:__________________ _ Lab #:__________ ifclo irts-5 icircie iRSis) , Heterotrophic Plate 1,. Trihalomethanes (524) 1. Purgeable Halocarbons (624/3260) BCount (hemodialysis & all others) Zi \ Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260) . CoWorm P/A (public supplies) ,,3/ Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624) , Coliform MPN (priv well, raw, stp) 4 Total Trihalomethane Potential (510) J "Sides (608/8080) . Fecal Coliform (all samples) 5. Microextractabies (504) , Microscopic 6. Pesticides (507) ; Macroscopic CO Pesticides/PCB screen (508) 8. PCB as Decachlorobiphenyl (508A)

a - a Herbicides (515) d 0; Pesticioes (525) 10. CTycoB in Water ,3,

ated? V8S no 11. Carbamate Pesticides (531) 12. Glyphosate (547) yes no ill 13. Diquat (549) 14. Chlorination Disinfection Byproducts (551) ilorine Res;: mg/L 15. Haioacetic Acids (552) 16. Other Pesticides (SM-18/6630) ilonne Ros; mq/L 17. Petroleurn/Hydrocarbon Scan (310-13) ,Z.PCB-ciA,pcn,o,s,(DEr,

______ .. _________ J

lie ANALYSES REQUESTED - Lab#:....... J.............. .....L2±_.._J.______ ■

fcllll 20. Acidity 39. Aluminum . 59. Potassium;

^■11 ... 21. Alkalinity, as CaCOd 22. Bromide 40. Antimony 41. Arsenic ■ ■H CO. S'-leniiim 61. Silver C? SC.-hE^EE iCtiVity 23. Bromate/Chlorate.'Chlorite 42. Barium ilvity (temp? ”0 24. Chloride 43. Beryllium # 63.'Thallium 6 cay) 25. Cyanide 44. Boron I 64..Vanadium e BOD (5 day) 26. Fluoride 45. Cadmium 5^Zinc

25;;”--' sssas:'-- risx-X. ■ naceous BOD (5 day) 27. Hardness, Total as CaCO.3 46. Calcium, as CaCO;) o B y vnromiurn. I otai (./. Vola'ilr:- .8^ slatlies ;=~ 31, Nitrogen, total ies/PCB’£ 32. Oil and Greas. i srooppe, D.- r'VEC.ii--

lenol . 52. Iron ci..p iosphol ■S. Total as F ES-Leaci :al icsphoj IS. Ortho as ;47Magnesiur .al Dissolved ilfates (5, Manganesi .al Volatile , .7i actai i

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