Chain of custody record with contact details, Westchester County

NYC 9/11 Public Portal Document

lU Utatichaftor County ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10^5 (914)593-5575 <- , ( / 7 C 1—NYS-ELAP No. 10108 Form A-70 (rev. 1/96) K Time/Date Set:__________ Sample Type (circle one): 1/ Potable 3. Non-Potable Treated Bottle #’s:. 2. Non-Potable Chain of Custody? yes no Time/Date Collected: ’ Comments: Collected Bv: V iN^lIXI Agency Code:____________ PW5 #:__________ Source ID: Type Descriptor: Collected From: Bill to: Location’s/lndividual’s' Name. Name/Company Street_____________________ Street___________ City/St/Zip_________ ;_______ City/St/Zip Identification of Source, Phone#: Fax #: ■' Collection Point UUXT) I CA. CH, Bl? Check#:Amounts \ BACTERIOLOGICAL ANALYSES, , ORGANI<y»OTABLE ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES . .T '5 f * * " •’

Lab#:_______________ .- Lab #: _________ L_____________ (circle tests) , ■ '(circle tests) t T. Heterotrophic Plate •- > 1. Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260) Count (hemodialysis & all others) 2. VoTatile Halocarbons (524) 2. Purgeable Aromatics (624/8260) 2. Coliform P/A (public supplies) 3. Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624) 3. Coliform MPN (priv well, raw, stp) 4. Total Trihalomethane Potential (510) 4. Phthalates (606/8060) 4. Fecal CofSorm (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8080) 5. Microscopic ' 6... Pesticides (507) 6. PCB's (Arochlors) (608/8080) 6. Macroscopic . Pesticides/PCB screen (508) 7. Herbicides (SM-18/6640; 8151) 2 7. API 8. -PCB as Decachlorobiphenyl (508A) - 8. Other Pesticides (SM-18/6630) 8. Other:______________________ 9. Herbicides (515) 9. Petroleum Hydrocarbon Scan (310-13) ,. (©Pesticides (525) 10. Glycols in Water Refrigerated? .yes. .no rr Carbamate Pesticides (531) 11. Acid Extractables (625/8270) 12. Glyphosate (547) I^Base Neutral Extractables (625/8270) , Chlorinated?: yes .no 13. Diquat (549) 'tsJgC/MS Unknown Scan 14. Chlorination Disinfection Byproducts (551) Purgeable Halocarbons (DEF) Free Chlorine Res: Jmg/L 15. Haloacetic Acids (552) 15. Purgeable Aromatics (DEF) 16. Other Pesticides (SM-18/6630) 16. Pesticides (DEF) Total Chlorine Res: mg/L 17. Petroleum/Hydrocarbon Scan (310-13) 17. PCB’s (Arochlors) (DEF)

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INORGANIC ANALYSES REQUESTED - Lab#:. (circle tests) 1. Color 20. Acidity Aluminum 59. Potassiums 2. Turbidity 21. Alkalinity, as CaCOs /40. Antimony p(A Selenium ! / 3. pH 22. Bromide 41. Arsenic 'ey Silver T ; 4. Conductivity 23. Bromate/Chlorate/Chlorite I 42.-Barium 62. Sodium ■; 5, Corrosivity (temp:______ °C) 24. Chloride V^/Beryllium (espThalhum <• 6. BOD (5 day) 25. Cyanide 44 Boron 64 Vanadiurri 7 Soluble BOD (5 day) 26. Fluoride 45. Cadmium yes.^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 Calcium. Ca*’ 66. Metals/CN 10. Dissolved Oxygen 29. Nitrogen, Nitrate as N Chromium. Total 67. Volatiles 11. Total Organic Carbon 30. Nitrogen, Nitrite as N Chromium. Hexavalent 68. Semi-volatiles 12. Total Organic Halides 31. Nitrogen, Total Kjeldahl as N zSoi Cobalt 69. Pesticides/PCB’s 13. Solids, Percent (%) 32. Oil and Grease 51 .jCopper 70. Disk Deliverables 52.flron 14. Solids, Settleable 33. Phenol TCLP 15. Solids, Suspended 34. Phosphorus. Total as P ^5:yLead 71. TCLP-Metais 16. Solids, Total 35. Phosphorus, Ortho as P JWk Magnesium 72. TCLP-Pesticides 17. Solids, Total Dissolved 36. Sulfates /55.tt)^anganese 73. TCLP-Herbicides 18. Solids. Total Volatile 37. Surfactants / 56.^ercury 74. TCLP-Volatiles jW) Other: _________ 38. UV254 I 57.^olybdenum 75. TCLP-BNA’s I 58/Nickel

NYC-WTC_000070987