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Chain of custody form, Westchester County Dept of Labs

Machine-extracted title · confidence 85%

Form tracking samples submitted to the Westchester County Department of Labs and Research.

NYC-WTC_000071567–000071574

Folder label: “26005

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Scanned page image, NYC-WTC_000071574
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NYC 9/11 Public Portal Document r

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM jester WESTCHESTER COUNTY LABORATORIES AND RESEARCH TOv.com 2 Dana Road, Valhalla, New York 10595 (914) 593-5575 •

^jme/Date Set: * c - NYS-ELAP No. 10108 Form A-70 (rev. 1/96) tztl ? -

Sample Type (circle one): Potable 3. Non Potable Treated Bottle 2. Non Potable 4. Other____________ Chain of Custody?___ yes___ no Time/Date Collected: Comments: Collected By: _ "'A^ncy Code: PWS #:______ Source ID: Type Descriptor: Collected From: BUI to: Location’s/lndividual’s Name Name/Company Street________________________ Street________ City/St/Zip____________________ City/St/Zip Identification of Source Phone#: Fax#: Collection Point_____ I CA,CH, Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLEZSOLID ANALYSIS Lab#:, Lab#:____ (circle tests) (circle tests) 1. Heterotrophic Plate 1. Trihalomethanes (524) J. Purgeable Halocarbons (624/8260) Count (hemodialysis & all others) r'2?\ Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260) 2. Coliform P/A (public supplies) VJ3/ 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) fcet:________ 8. PCB as Decachlorobiphenyl (508A) 9^ Herbicides (515) 8. Herbicides (EPAI 978/8151) 9. Pesticides (SMI 8/6630) (io) Pesticides (525) - 10. Petroleum Hydrocarbon Scan (310-13).-.-; Refrigerated?yes no 11. Carbamate Pesticides (531) 11. Glycols V.., Chlorinated:? yes no 12. Glyphosate (547) 12. Acid Extractables (625/8270) 13. Diquat (549) 11 Base Neutral Extractables (625/8270) Free Chlorine Res:. mg/L 14. Chlorination Disinfection Byproducts (551)' Q4)gc/MS Semivolatile Unknown Scan Total Chlorine Res: mg/L 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 (PEF) 18. Other: > • "^{8. Other: ■

INORGANIC ANALYSIS REQUESTED - Lab#: o (circle tests) 1. Color 20. Ajidity 39. Aluminum 59. Potassiurn «•»> 2. Turbidity 21. Alkalinity, as CaCOs 40. Antimony 60. Selenium v 3. pH 22. Bromide 41. Arsenic 61. Silver j f^l j 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 I 8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOs 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 33. Phenol 52. Iron

f Solids, Settleable Solids, Suspended 34. Phosphorus Total as P 53.Lead ICJLE 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_000071574

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NYC-WTC_000071574Source: NYC Law Department, mirrored locally

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