Chain of custody form, Westchester County Dept of Labs

NYC 9/11 Public Portal Document

III ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 LUortcbertOf County (914) 593-5575 NYS-ELAP No. 10108 Time/Date Set:______________ ____________________ _ Form A-'^ (rev 1/96) Sample Type (circle one): 7 7 7.6.^4. J Potable 3. Non-Potable Treated Bottle #’s:__________ 2. Non-Potable 4. Other_________ _______ _______ _ Chain of Custody? yes no Time/Date Collected: <7 1 /fl'' A Comments: Collected Bv: Agency Code: PWS #:___________ Source ID:. .Type Descriptor:. Collected From: Bill to: Location’s/lndividual's Name. Name/Company Street__________________ Street_____________ City/SVZip______________ City/St/Zip_________ Identification of Source. Phone#:, Fax #: Collection Point, I CA, CH. Bl? Check#: Amounts. ___________ __________________ BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES Lab#:______________________ Lab #:________ 2_____________ __ (circle tests) ri; (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) 1 3. Coliform MPN (priv well, raw, stp) 45 Total Trihalomethane Potential (510) 4. Phthalates (606/8060) 4. Fecal Coliform (all samples) 5. Microextractables (504) 5. Organoctilorine Pesticides (608/8080) 5i Microscopic 6. Pesticides (507) ‘6. PCB’s (Arochlors) (608/8080) A* 6. Macroscopic J? Pesticides/PCB screen (508) 7. Herbicides (SM-18/6640; 8151) 7. API 8. PCB as Decachlorobiphenyl (508A) 8. Other PesticidesJSM-18/6630) • 8. Other:___________________ 9^ Herbicides (515) 9. Petroleum Hydrocarbon Scan (310-13) , x..- Pesticides (525) 10. Glycols in Water Refrigerated? yes. .no 41. Carbarnate Pesticides (531) 11. Acid Extractables (625/8270) 12. Glyphosate (547) J i Base Neutral Extractables (625/8270) Chlorinated?: yes. .no 13. Diquat (549) "l 3JGC/MS Unknown Scan ,14. Chlorination Disinfection Byproducts (551) 14. f?urgeable Halocarbons (DEF) .1 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 (31043) 17. P'CB’s (Arochlors) (DEF) M-

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INORGANIC ANALYSES REQUESTED^iab#: (circle tests) 1. Color 39. Aluminum 59. Potassium 2. Turbidity 2H,A^alinity, as CaCOa 40. Antimony 60. Selenium 3. pH , 2ijr Bfcmide 41. Arsenic 61. Silver 4. Conductivity 22(: Bfemate/Chlorate/Chlorrte ' 42. Barium 62. Sodium 5. Corrosivity (temp: .°C) 24.-C_hloride 43. Beryllium i 63. Thallium 6. BOD (5 day) ,2^ Cyanide 44. Boron i 64. 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 CaCOa CLE 9. Chemical Oxygen Demand 28. Nitrogen, Ammonia as N' 47. Calciurr),"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. I. IV254 57. Molybdenum 75. TCLP-BNA’s 58. Nickel

NYC-WTC_000071534