Chain of custody form, Westchester County Dept of Labs

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ester WESTCHESTER COUNTY LABORATORIES AND RESEARCH ov.com i 2 Dana Road, Valhalla, New York 10595 (914) 593-5575 NYS-ELAP No. 10108 Tune/Date Set: Form A-70 (rev. 1/96)

Sample Type (circle one): ' 1. Potable , 3. Non Potable Treated Bottle #’s:________________ '5'5 o-T>______________________ £ Non Potable 4. Other Chain of Custody?___ yes___ no Time/Date Collected: _________ Comments:__________________ Collected By: Agency Code: PWS #:______ Source ID: Type Descriptor: Collected From: Bill to: Location’s/lndividual’s Name _ hl' Name/Company Street___________________ Street________ City/St/Zip________________ City/St/Zip Identification of Source Phone#: Fax#: Collection Point \ VP CA.CH, Bl? Check#: Amounts

BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS Lab#:_______________________ Lab#:____ i / (circle tests) ! r~ (circle tests) 1. Heterotrophic Plate 1. Trihalomethanes (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 (7. Pesticides/PCB screen (508) 7. Methoprene (616) 8, PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPAI 978/8151) [her: 9. Herbicides (515) 9. Pesticides (SMI8/6630) . ' (jci- Pesticides (525) 10. Petroleum Hydrocarbon 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) 13. Base Neutral Extractables (625/8270) Free Chlorine Res:. mg/L 14. Chlorination Disinfection Byproducts (551) (jpGC/MS Semivolatile Unknown Scan Total. Chlorine Res: < 15. Haloacetic Acids (552) 15. Purgeable Halocarbons (DEF) 16. Pesticides (SMI8/6630) ' 16. Purgeable Aromatics (DEF) PH^___ ■'17. Petroleum/Hydrocarbon Scan (310-13) , 17. Pesticides/PCB's (DEF) 18. Other:__________________ _______ . 18. Other_______________ :__________ 1 INORGANIC ANALYSIS rBQUESTED - Lab#; tXJ . (circle tests) .■ 39. Aluminum A ... •<i. Color 20. Acidity 59. Potassium 1 r 2. Turbidity 21. Alkalinity, as CaCOs 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:__ »C) 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 CaCOs 46. Calcium, as CaCOs CLE 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-violatiles 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 Solids, Settleable 33. Phenol 52. Iron , TCLP Solids, Suspended 34. Phosphorus Total as P 53.Lead 71 TCLP-Metals 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. UV254 57 Molybdenum 75.TCLP-BNA’s 58. Nickel

NYC-WTC_000071570