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Chain of custody form, Westchester County Labs

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Document tracking the custody and handling of environmental samples submitted to Westchester County Department of Labs.

NYC-WTC_000071429–000071436

Folder label: “27188

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NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM tester govcom 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)

Sample Type (circle one): ijpotable 3. Non Potable Treated Bottle#’s: , C ^2?-_____________

2. Non Potable 4. Other Chain of Custody?___ yes___ no Time/Date Collected: '•* \ - Comments:__________________ Collected By: "X > R < A Agency Code: PWS #:______ Source ID: Type Descriptor: Collected From: Bill to: Location’s/lndividual’s Name 3* Name/Company Street_________________ Street________ City/St/Zip______________ City/St/Zip Identification of Source Phone#: Fax#: Collection Point 3 I C.A.CH, Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS ORGANIC POTA^AjaALYSI^ ORGANIC NONPOTABLE/SOUD ANALYSIS Lab#:_______________________ (circle teste) y / f (circle tests) 1. Heterotrophic Plate 1. Trihalometharl^^(524) 1. Purgeable Halocarbons (624/8260) Count (hemodialysis & all others) 2. Volatile 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 (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) 6. Macroscopic Pesticides/PCB screen (508) 7. Methoprene (616) 7. API 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPAI 978/8151) 8. Other:__________________ __ 9. Herbicides (515) 9. Pesticides (SMI 8/6630) Refrigerated?yes no 10. Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13) 11. Carbamate Pesticides (531) 11. Glycols Chlorinated:? yes no 12. Glyphosate (547) 12. Acid Extractables (625/8270) 13. Diquat (549) 13. Base Neutral Extractables (625/8270) Free Chlorine Res: mg/L i J-GC/MS Semivolatile Unknown Scan 14. Chlorination Disinfection Byproducts (551) Total Chlorine Res:^ mg/L 15. Haloacetic Acids (552) 15. Purgeable Halocarbons (DEF) 16. Pesticides (SMI 8/6630) 16. Purgeable Aromatics (DEF) pH ___________ 17. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB’s (I 18. Other;__________________________ 18.Other:n_J^

INORGANIC ANALYSIS 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:. 5C) 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 CaCOa 46. Calcium, as CaCOs CLP 9. Chemical Oxygen 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-vioiatiles 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 15. Solids, Suspended 34. Phosphorus Total as P 53.Lead IfikE 54 Magnesium 71 TCLP-Metals 16. Solids, Total 35. Phosphorus, Ortho as P 55 Manganese 72.TCLP-Pesticides 17. Solids, Total Dissolved 36. Sulfates 56. Mercury 73.TCLP-Herbicides 18. Solids, Total Volatile 37. Surfactants 74. TCLP-Volatiles 19. Other:_________________ 38. UV254 57 Molybdenum 75.TCLP-BNA'S 58. Nickel

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