Chain of custody record, Westchester County Department of Labs

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM tv.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. 1/96)

^ywplA (circle one): r C '•-W I 1. Potable } 3. Non Potable Treated Bottle j <0 17 , A I 7, A 7 ^7 2. Non Potable 4. Other Chain of Custody?___ yes no Time/Date Collected: M S Comments:_____________________ Collected By: Agency Code: PWS#;_______ Source ID: .Type Descriptor: Collected From: BUI to: Location’s/lndividual's Name yA *1 Name/Company Street__________________ ;__________________________ Street________ City/St/Zip _ ________ ________________________________ City/St/Zip Identification of Source____ _ ______ __ ________________ Phone#; Fax#; Collection Point ________ - I CA.CH, BI? Check#: Amounts.

BACTERIOLOGICAL ANALYisiS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLEZSOUD ANALYSIS Lab#: _ ______________________ Lab#; ■ (circle tests) (circleteste) 1. Heterotrophic Plate V WIpmethanes .(52^).,;_ 1. Purgeable Halocarbons (624/8260) Count (hemodialysis & all others) -/;^Yi(ela(fl»+laleeaibeR^ 2. Purgeable Aromatics (624/8260) 2. Coliform P/A (public supplies) Afalatile Aromntie J (cad), 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 y 6. 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 (EPAI 978/8151) 8. Other_____________________ Herbicides (515) 9. Pesticides (SMI8/6630) Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13) Refrigerated? yes no Carbamate Pesticides (531) 11. Glycols Chlorinated:? yes no 12. Glyphosate (547) 12. Acid Extractables (625/8270) 13. Diquat (549) (^Base Neutral Extractables (625/8270) Free Chlorine Res:. mg/L 14. Chlorination Disinfection Byproducts (551) U. GC/MS Semivolatile Unknown Scan Total Chlorine Res: mg/L 15. Haloacetic Acids (552) 15. Purgeable Halocarbons (DEF) 16. Pesticides (SM18/6630) 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. Ajidity 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. 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. Calcium, Ca*2 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 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. UV254 57 Molybdenum 75.TCLP-BNA's 58. Nickel

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