Chain of custody record with contact details, Westchester County

NYC 9/11 Public Portal Document

ENVIRONiyiENTAL SERVICES SAMPLE SUBMISSION FORM Q , 0 tv.com WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road. Valhalla. New York 10595 ,, ’

(914)593-5575 ' NYS-ELAP No. 10108 ■ ^p/DateSet: Form A-70 (rpv.1/96)

Sample Type (circle one): /■l^otable 3. Non Potable Treated 2. Non Potable 4. Other Chain of Custody? yes no Time/Date Collected: Collected By: &S MS- Comments: Agency Code: PWS #;_______ Source ID: .Type Descriptor: Collected From: Bill to: Location’s/lndividual’s Name ~ ; Name/Company Street p/ ( f iFS-'t tf-VZe Street________ City/St/Zip Mu-l her Ufi City/St/Zip Identification of Source ______ __ _______________ _ Phone#: Fax#: Collection Point < t- iF)____________ CA,CH, Bl? Check#: Amounts

BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLEZSOLID ANALYSIS Lab#:___________ _ __________ Lab#:________________________ (circle tests) (circle tests) _ 1. Heterotrophic Plate I. 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) kj3/Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624) 3. Coliform MPN (priv well, raw, stp) 4. Total Trihalpmethane Potential (510) 4. Phthalates (625/8270) 4. Fecal Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8081) 5. Microscopic 6. Pesticides (507) 6. PCB’s (Arochlors) (608/8081) |J||croscopic 0 Pesticides/PCB screen (508) 7. Methoprene (616) 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPAI 978/8151) 8. Other/ _________ X Herbicides (515) 9. Pesticides (SM18/6630) - Qp) Pesticides (525) 10. Petroleum Hydrocarbori Scan (310-13) Refrigerated? yes .no 11. 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) ^GC/MS Semivolatile Unknown Scan 15. Haloacetic Acids (552) 'TS. Purgeable Halocarbons (DEF) Total Chlorine Reis: mg/L 16. Pesticides (SMI8/6630) 16. Purgeable Aromatics (DEF) pH _ 17. Petrofeum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB’s (DEF) 18. Other:. 18. Other:L X^^^,

INORGANIC ANALYSIS REQUESTED - Lab#: (circle tests) 1. Color 20. Acidity.,, 39. Aluminum 5^ Potassium 2. Turbidity 21. Alk^lini^, as CaCOs 40:^ntimony ■60. Selenium 22. Bromide YT^rsenic 61. Silver 3. pH 4. Conductivity 23. Bromate/Chlorate/Chlorite 42. Barium .. Sodium 5. Corrosivity (temp:. ,®C) 24. Chloride XS^eryllium Thallium 6. BOD (5 day) 25. Cyanide Boron 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 ^J>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-violatiles 12.^Total Organic Halides ■5 31. Nitrog^/jTctal Kjeldahl as N r^Cobalt 69.Pesticides/PCB's 32. Oil anGrease Vl Copper Solids. Percent ■ (%) 70. Disk Deliverables ^Kolids. Settleable ' ■ ,.'33:Phen»Y----Y (^Irori .......... '///'/■

^^So I ids. Suspended 34. Phosp^SnJS Total as P ^Lead Zs^Magnesium • 71 TCLP-Metals ■ < T 6. Solids. Total : 35. Phosphorus, Ortho as P 72.TCLP-Pesticides . 17. Solids. Total DlMolved ; 36. Sulfates; . ' U^anganese 73.TGLP-HerbiQides a ia Solids. Total Volatile : ' / C 37. Surfactants ' " 38. UV254 ‘ ' /‘504olybdenum 74. TCLP-Volatiles, - pother: SnHf-----------

NYC-WTC_000071244