Chain of custody form, Westchester County Dept of Labs

NYC 9/11 Public Portal Document — —

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ster iv.com WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 ' (914) 593-5575 NYS-ELAP No. 10108 ^m^/pate Set: Form A-70 (rev. 1/96)

Sample Type (circle one): T77 1. Potable 3. Non Potable Treated Bottle #’s: 2. 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/lndividuars Name , Name/Company Street _^2__________ — Street_________ City/St/Zip____________ City/St/Zip_____ : Identification of Source / > -'Phone#: Fax#: Collection Point______ CA.CH. Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS Lab#:_______________________ Lab#:__________ 1 , ■ ; . (circle tests) (circle tests) 1. HetdVbtrophic Plate 1. Trihalometharies (524) 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) 3. Coliform MPN (privwell, raw.stp) 4. Total Trihalomethane Potential (510) 4. Phthalates (625/8270) 4. Fecal Coliform (all samples) -9; Microextractables (504) 5. Organochlorine Pesticides (608/8081) < 5yMicroscopic 6. PCB’s (Arochlors) (608/8081) e^acroscopic ’(3 Pesticides (507) > Pesticides/PCB screen (508) 7. Methoprene (616) 8. PCB as Decachlorobiphenyl (508A) \ 8. Herbicides (EPAI 978^151)- ■ ^TOher:__________ < a Herbicides (515) V. 9. Pesticides.fSMl8/6^0) ■

y QO) Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13) Refrigerated? yes __’-no 1'1 Carbamate Pesticides (531) 11. Glycols Chlorinated:? yes ___ no 12. Glyphosate (547) 12. Acid Extractables (625/8270) 13. Diquat (549) 14< Base Neutral Extractables (625/8270) Free" Chlorine Res: 14. Chlorination Disinfection Byproducts (551) Q^GC/MS Semivolatile Unknown Scan Total Chlorine Res: 2. 15. Haloacetic Acids (552) 15. Purgeable Halocarbons (DEF) • 16. Pesticides (SMI 8/6630)-. •- .16.' Purgeable Aromatics ’(DEF) pH 17. Petroleum/Hydrocarboh Scan (310-13) ’iy.Pesticides/PCB’s^DeF) r 18. Other___________L_____________ ■ 18. Other ■ '

INORGANIC'ANALYSIS REQUESTED - Lab#: (circle tests) . • v '> ..’0? 1. Color 20. Ajidity 39. Aluminum ' 59. Potassium ; 2. Turbidity -I- 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 c 5. Corrosivity (temp: .“C) J 24. Ghidride j’- 43. Beryllium 63. Thallium . 6. BOD (5 day) 25. Cyanide ' * 44. Boron ' ' 64. Vanadium 7. Soluble BOD (5 day) i 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-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 ^BSolids, Suspended TCLP 34. Phosphorus Total as P 53.Lead lT Solids, Total 71 .TCLP-Metals 35. Phosphorus, Ortho as P 54 Magnesium 72.TCLP-Pesticides 17. Solids, Total Dissolved / 36. Sulfates 55 Manganese 18. Solids, Total Volatile 1' 73.TCLP-Herbicides 37. Surfartants 56. Mercury 19. Other:_______________ / 57 Molybdenum 74. TCLP-Volatiles 38. UV254 75. TCLP-BNA’s 58. Nickel

NYC-WTC_000071572