Chain of custody record with contact details, Westchester County

NYC 9/11 Public Portal Document

III ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road. Valhalla, New York 10595 UtosicheitBr County NYS-ELAP No. 10108 (914) 593-5575 n J Time/Date Set:_________________________ Form A-70 (rev. 1/96) Sample Type (circle one): '..1' 'T. Potable’J 3. Non-Potable Treated Bottle #’s:. Noi>Potable 4. Other______ Chain of Custody? .yes no Time/Date Collected: U ' iTTurni I Comments: Collected Bv: .. - ■- zi'i ■//if Agency Code: PWS #:_________ 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 Sourco_,j^_______ Phone#:________ Fax#: CollectionPoint I CA. CH. Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES Lab#:________ ;___________ _ Lab #:____________________________ (circle tests) (circle tests) 1. Heterotrophic Plate 1. Trihalomethanes (524) 1, Purgeable Halocarbons (624/8260) Count (hemodialysis & all others) Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260) 2. Coliform P/A (public supplies) 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 Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8080) ’6. 5. Microscopic Pesticides (507) PCB's (Arochlors) (608/8080) 6. Macroscopic I Pesticides/PCB screen (508) 7. Herbicides (SM-18/6640; 8151) 7. API 8. PCB as Decachlorobiphenyl (508A) 8. Other Pesticides (SM-18/6630) 8. .Other:____i_;___________ Herbicides (515) 9. Petroleum Hydrocarbon Scan (310-13) Pesticides (525) 10. Glycols in Water Refrigerated? ves no 11. Carbamate Pesticides (531) 11. Acid Extractables (625/8270) 12. Glyphosate (547) 1Z Base Neutral Extractables (625/8270) Chlorinated?: ves no 13. Diquat (549) 3. IS Unknown Scan 14. Chlorination Disinfection Byproducts (551) TZT Purgeable Halocarbons (DEF) Free Chlorine Res: .mg/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)

..it r-v C INORGANIC ANALYSES REQUESTED - Lab#: (circle tests) * * 1. Color 20. Acidity 39. Aluminum 59. Potassium 2. Turbidity 21. Alkalinity, as CaCOa 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 eS^Zinc________ 8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOa 46. Calcium, as CaCOa CLE 9. Chemical Oxygon 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-volatiles 12. Total Organic Halides 31. Nitrogen, Total Kjeldahl as N 50. Cobalt 69. Pesticides/PCB's 13. Solids, Percent (%) 32. Oil and 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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