Chain of custody form, Westchester County Dept of Labs

NYC 9/11 Public Portal Document

4 ' ENVIRONMENTAL’SERVICES SAMRLt SUBMISSION FORM/ WESTCHESTER COUNtY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 - - . ■ (914) 593-5575 <, . NYS-ELAPNo. 10108 . ^^e/Date Set:’ Form A-70 (rev. 1/96) /

Sample Type (circle one): ' I, Potable \3, Non Potable Treated 2, Non Potable 4. Other______________ - Chain of Custody? yes no Time/Date Collected:. Z/A-j-T.A / Comments: Collected By: /YTT; tvM'/l/j^gen'cy Code: PWS #:_______ _ Source ID: Type Descriptor; Collected From: Bill to'; Location’s/lndividual’s Name /V yc be P/<- n Nam^ompany _

Street / Y t/C____________ 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, Heterotrophic Plate 1.-Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260) - i 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 (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) rr0 . ,5, Microscopic 6, Pesticides (507) 6. PCB’s (Arochlors) (608/8081) ^^acroscopic Pesticides/PCB screen (508) 7. Methoprene (616) - ^ther: ___________________ 8, PCB as Decachlorobiphenyr .(508A) 8. Herbicrdes (EPAI 978/8151) '0^ Herbicides, (515) 9. Pesticides (SMI8/6630)’ ' ■

(l^ Pesticides' (525) 10. Petroleum Hydrocarbon Scan (SIO-IS) .--? 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) ^,^GC/MS Semivolatile Unknown Scan Total Chlorine Res: _______ mg/L 15, Haloacetic Acids (552) 15. Purgeable Halocarbons (DEF) 16, Pesticides (SM18/6630) 16. Purgeable Aromatics (DEF) pH 17, Petroleum/Hydrdcarbon Scan (310-13) 17. Pesticides/PCB’s (DEF) 18, Other:_________________________ 18. Other: ' '' ; c ! INORGANIC ANALYSIS REQUESTED,- Lab#: (circle tests) 1. Color 20. Acidity , 39. Aluminum Potassium 2. Turbidity 21. Alkalinity, as CaCOs '• ^^’Antimony 60. Selenium 3. pH 22. Bromide 41. Arsenic 61. Silver J 4. Conductivity ■ 23. Bromate/Chtorate/Chlorite 42^ Barium /g2'.'Sodium 5. Corrosivity (temp:. «C) 24. Chloride .‘Beryllium i63.'ThaHium 6. BOD (5 day) 25. Cyanide 44, Boron \6^'Vanadium ’ ■ 7. Soluble BOD (5 day) 26. Flud ’ride 45. Cadmium 65. Zinc 8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOs 46. Calcium, as CaCOs CLP 9. Chemical Oxygen Demand 28. Nitrogen, Ammonia as N ^2^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 l^.'^Total Organic Halides - 31, Nitrogen, Total Kjeldahl as N @X3obalt 69, Pesticides/PCB’s 13. Solids, Percerit (%) 32, Oil an.’G^rea^’ 51^ Copper 70, Disk Deliverables ■ M.-Phen^l^'“ - <^)lron J Solids; Settleable.. TCLP Solids, Suspended • . '• 34, Phosphorus Total as P- . 53..tead? ' ■ ‘ 35,' Phospl^rus; Ortho as P 71 .TCLP-Metals 16. Solids, Totaf , ’ ■/54\Magnesium ■■^5?Manganese ' 72,TCLPrPesticides \ ‘ 17. Solids, Total Dissolved 36, Sulfas, ' * \ .5- 73.,TCLP;Herbicides 18.:Solids, jotal^olatiie. 37. SurfM(ants; ■ ■ ■ 74,<rCLR-Voiatiles ■ ' ' ■ia'.dthey^S.^MT- " ■ , \38? LIV254^ ■ ^)Molybdenum . 58>^kel; 7 ; JS'JCLP-BNA’s’ •' •• _ NYC-WTC_000071635