Chain of custody form, Westchester County Dept of Labs

NYC 9/11 Public Portal Document

/ENVIRONMENtAL-SERVICES SAMPLE^UBMISSION FORM jester " WEStCHESTER\cbyNfY^^BORAtdRIE§"ANfr gov.com ..4 '. 2 Dana Road, .Valhalla, New York 10595..- . .. .. t '(OU) 593-5575 ' - ' ^YS-ELAP No. 10108' Tujne/Date Set: , a) Form A-70 (rev. 1/96)

S^ple Type (circle one):

1. Potable 3. Non Potable Treated Bottle . 2. Nori Potable 4. Other ______ Chain of Custody?.yes '' rio Time/Date Collected: Comments: . Collected By: __ ^2 Agency Code: PWS #:______ Source ID: ^Type Descriptor: Collected From: Bill to: Location’s/lndividual’s Name ' Name/Company Street 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#:________________________ (circle tests) (circle tests) .- 1. Heterotropl^.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) <3? Volatile Arornatics (524) 3. Acrolein & Acrylonitrile (624) i ’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 Q) Pesticides/PCB screen (508) , 7..‘Methoprene'(616) 8. PCB as Decachlorobiphenyl (SOSA) . 8.<Hei£ieides(EPAI 978/8151) Herbicides (515) 9. Pesticides'(SMI8/6630) ‘ Pesticides (525) io.' Petroleum Hydrocarbon Scan (310-13) ;-’ Refrigerated? _ yes no 11. Carbamate Pesticides (531) • IT.’Glycols , rz 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) M^JgC/MS Semivolatile Unknown Scan mg/L 15. Haloacetic Acids (552) 15. Purgeable Halocarbons (DEF) Total Chlorine Res: 16. Pesticides (SMI8/6630) 16. Purgeable Aromatics (DEF) pH 17. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB’s (DEF) 18. Other:__________________________ 18. Other:__________________ _ ■■

INORGANIC ANALYSIS REQUESTED - Lab#: ( (Y-"! V (circle tests) •Of. ■J3, '3Sk Aluminum <39^ PotassiunrA-fi I 1. Color 20. Acidity 21. Alkalinity, as CaCOs ^'4Q)Antimonv 60. Selenium it 1/^1 2. Turbidity 3. pH 22. Bromide 41 .Arsenic y. Silver - 4. Conductivity 5. Corrosivity (temp:. 6. BOD (5 day) .“C) 23. 24. Bromate/Chlorate/Chlorite Chloride 25. Cyanide 42. Barium ^^eryllium 44. Boron Sodium <g3>Thallium Vanadium | I 7< Soluble BOD (5 day) 26. Fluoride 45. Cadmium 65. Zinc - I 8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOs 4^ Calcium, as CaCOs . CLP 28. Nitrogen, Ammonia as N (^Calcium, CaY 9. Chemical Oxygen Demand 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. Chromium, Hexavalent. 68. Semi-violatiles ,12/Total Organic Halides 31. Nitrogen, Total Kjeldahl as N Cobalt .69'^Pesticides/PCB’s 13.'Solids,'Percent (%) 32. Oil an Grease 51 .Copper • • • )70. Disk Deliverables ‘^^'Solids, Settleable .33. PhenoL ' 52/Iron ■■ .^'5 TCLP. i^Asolids, Suspended 3 4. Phosphorus Total as P 53.Lead YJ.TCLP-Metals, '^^Soiids; Total ' 35. .Phosphorus, Ortho as P ‘ Ma-g_nesium'- ‘72:TCLf’-F;esticides^ ’ 17.'l^olids;’ Total Dissolved .'36. Sulfates i Manganese, 4, i73.'-TCL'P-Hefbicidesl 18/Soiicis, Total Volatile. . 37.^SurfactantS' ' ' J56?Mercuryi j74;TCtR-V6l^iie^ 38.’’0'V254j ■f5z)Moiybd^um'i ^Sg?Nickel ' ■ 75,TCL5-BNAi' »- Illi «l ♦!-.» J . r-

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