Chain of custody form, Westchester County Labs

NYC 9/11 Public Portal Document

BBS ENVIRONMENTAl, SERVICES SAMPLE SUBMISSION FORM i |l| WESrCHESTEBCOUNTVLABOnA.onirsANORESFARCH ®oW.S 2 Dana Road, Valhalla. New York 1059b

(914) 593-5575 Fol Sample Type (circle one); f A fc. ■

jSPotabie 3. Non-Potable Treated Bottle

I 2. Non-Potable 4. Other ' __ ;_______________ Custody?yes Chain of Custody? no ^ TimeZDafe Collected;__ a? ' i u * 19 ' A_ _________ Comments: 1 : ' '

Collected By: (__ L;_uL.A_A--..—______ Agency Code ■ IBM|^W|W|BiB| Source ID: CoVected From- Bill to: ■ ' •• )n’s/lndividual's Name ~ _______ Name/Company ’street_Li__ C- 'iV. , __________________ . Street, City'SvZip_ i„2.LilLlir:___ LiA„..L£Li 9;: City/SVZip____________ • Identification of Source__________ \__ ___ _____________ Phone#;____ ) Fax #: I ion Point__li£2±ll_____ I__________________ TcA^ CH, Bl?J Check#: Amount®

/bactebioiogicai.analyses yfiUANICl't.'rABU ANALV.SI.S OUGAMIC MWPOIABll ZSOLIU AL.'LF

; Lab#; __ ____ ________________ iarctewsts) 9nMMSMnnMl^K$:-Y !citc!eiesisv'S -. ^ /p4^ S .0-0 ■ ■ 1. He'erotroohic Plate Trihaiomethanes (S24) 1. Purgeable Halocarbons (624/8260) 'H I Count (hemodialysis & all others) Volatile Halocarbons (524) 2, Purgeabie A’-ornatics (624/8260) J • ' ■ ?. Coilform P/A (public supplies) JJ/ Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624) , J 3, Colilotm MPN Ip* well. raw. stp) 4, Total 1 nnaiomethane Potential (;5^ 4. Phthalates (606/8060) 1 4 Fecal CoBorm (al! samples) 1 {ssxr*^- 5. Organochiorine Pesticides (608/8080) 6, PCT’S (Arochlors) (608/8080) 7. Herbicides (SM-18/6640; 8151) 7 API 9 ;s^jssKf«»A, 8. Other Pesticides (SM-18/6630) : H.Olbec--------------------------------

Refrigerated?yes no 11 C-bnm;,tclVchcm-(5-1) 9. Petroleum Hydrocarbon Scan (310-13’ 10. Glycols in Water 11. Acid Extractables (625/8270) ■ It

( Chlorinated?; yes no sKsr si;S:;:. S~~-— . .........................

“'s:’"......... I i tl Free Chjonne Res:mg/L 16. Other Pesticides (SM-18/6630) 16. Pesticides (DEF) . ......................... . ioUiCiPor, nenes:----- i mo. 17. PetroIeunVHydrocarbon Scan (310-13) 17. PCB's (Arochlors) (DEF) 9 _.£]±r.r.m..r.-r.=..r=(.^==.______________ I ■ I _L”L_’J__ 2_________ -_ ________ ___________ . , INORGANIC ANALYSES REQUESTED ^Lab#:.______________

■ .... ;“C

3. pH - 22. Bromide 39. Atuminumi

M0| Anttmony ' issr 61. Silver 4. Conductivity 23, Erdmale/Chlorate/Chlonte ;62.-‘Sodium 5. . Corrosivity (temp:----------- X) 24. Chloride Z43. Beryllium 44. Boron 76$. Zinc

■ I 41 Ss. Chrornium, Total Cll.' 66. Metals/CN {' 7. Vo dtl'P: 49, Chromium, Hexavalei ;>eni: V, U; I' s: <50. Cobalt 51. Copper . A? Disk D-i:vn;ai :e:. i r4 Iron , losphorus. lota! as P losphorus. Ortho as Pi la’es ' ■ rSi

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