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Chain of custody form, Westchester County Labs

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Form recording the chain of custody for environmental samples submitted to the Westchester County Department of Labs.

NYC-WTC_000071478–000071481

Folder label: “27274

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NYC 9/11 Public Portal Document IU. ENVIRONMENȚAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595' Ichester County (914), 593-5575 .NYS-ELAP No. 10108 -Time/Date Set: GEBY310•31 0-414 Form A-70 (rev. 1/96) Sample Type (circle one): 068:428 8-7590733 1 Potable 3. Non:Potable Treated Botle #'sL 0500 KTB 0248.K.E75 K•EDErK-5 2 Non-Pötable™ 4. Oiher = Chain of Custody? .yes.no Time/Date Collected:14: 3Q M/o/c1 Collected By: Huindier .і.-: "Comments:_ Agency Code: PWS #: Source ID: _Type Descriptor: Collected From: Bill to: Location's/Individual's Name. NyC DEP Street 1 4 Wositake Street Cityisuzip_Valhalla Dsivt Name/Company- NV 10573 City/SV/Zip. Identification of Source. Phone#: Fax #: Collection Point_ CRC ON CA, CH, BI? Check#: Amounts BACTERIOLOGICAL• ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES Lab# (ciréle tests) 1. Heterotrophic Plate Count (hemodialysis & all others) 2 Coliform P/A (public supplies) 3: Coliform MPN.(priv. well, raw, stp) 4: Fecal Coliform (all samples). -5. Microscopic 6. Mäcroscopic i 7. APi :8.-Other: ¡Refrigerated? Chiorinated?: Free Chlorine Res: TotalChlorine Res: _yes_ •. nO yes" no mg/L mg/L. •(circle lests) Trihalomethanes (524) 3) Volatile Aromatico (524) Volatile Halocarbons (524) 14 .5 Totạl Trihalomethane Potential (510) Microextractäbles (504) Pésticides (507) Pesticides/PCB screen (508) PCB äs Decachlorobiphenyl (508A). Hérbicides (515). 10 Pesticides (525) Carbamate P.esticides.(531) 12. Glyphosate (547): 3. Diquat (549) 14. Chlorination Disinfection" Byproducts (551)' 115. Haloacetic Äcids (552) 16. Other Pesticides (SM-18/6630) 417. Petroleum/Hydrocarbon Scan (310-13) 1. Purgeable Halocarbons (624/8260) 2. . Purgeable Aromatics (624/8260) 3. Acrolein & Acrylonitrile (624) 4.. Phthalates: (606/8060) Organochlorine Pesticides (608/8080) 6: PCB's (Arochlors) (608/8080) Herbicides (SM-18/6640; 8151) 8: Other Pesticides (SM-18/6630) 9. Petroleum Hydrocärbon Scan (310-13) 10, Glycols, in Water: 11:Acid Extractables. (625/8270) 12 Bäse Nøuiral Exractables (62578270) 13) GC/MS Unkriown Scan 14. Purgeable Haloçarbons (DEF 15. Pürgeable Aromatićs (DEF)' 16. Pesticides (DEF) 17 PCB's (Árochlors) (DẸF) Millio INORGANIC ANALYSES REQUESTED gLab# (circle tests) Color 2: Turbidity 3. 4. 5. 6. Conductivity Corrosivity (temp: BOD (5 day) Soluble BOD (5 day) 8.: Carbonaceous BOD (5 day) 9. Chemical Oxygen Demand 10: Dissolved Oxygen 11! Total Organic Carbon 12. Total Organic"Halides› p13:Soldș; Percent (%): {14. Solids, Settleable, 15: Solids, Suspended) i6. 17g Solids) Total Dissolved] 18 Ohet: : Solids Total,Volatile, 20. Acidity , Alkalınny, as CaCO3 22. Bromide °C) +23-Bromate/Chlorate/Chlorite *244 Choride 25Cyanide 26. Fluoride 27. Hardness, Total as. CaCO3, 28:Nitrogen, Ammonia as N: 29.1Nitrogen; Nitrate as N 3Ộ: Nitrogen: Nitrite as N° 31 Nitrogen, Total Kjeldahl as N) 32 Oiland Grease; 33 Phenol) 34 Phosphorus: Total as P! 35 Phosphorus; Ortho as P) 36: Sulfates] '37 Surtactants, 3821 39. Aluminum: 40: Antimony . Arsenic 42 Barium 43. Beryllium .44. Boron, 45 Cădmium 46Calcium:as, CaC03. A7/ Calcium, Ca* 484 Chromium, Total 49. Chromium, Hexavalenti 50) Cobalt: Sft Copper? lion> Leadi _Magnesium; › Manganese 56!, Mercury, k Mölyödenumì 60. Selenium _61 Silver Sodium Thallium Yinadium Zinc. CLP/ 66 Metals/CN: 167-Volatiles; :68. Semi-vólatiles (69 Pesticides/PCB's, S704Disk Delverables ITCLP! 71! TCLP Mètals: {72: TCLP Pesticides) 73:TCLP Hörbicides? 74:TCLP-Volatiles 75. TCLP BNA'S NYC-WTC_000071480

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NYC-WTC_000071480Source: NYC Law Department, mirrored locally

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NYC-WTC_000070245 · Box DEP Box 61

Record documenting the chain of custody for samples submitted to the Westchester County Department of Labs and Research.

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