Chain of custody form, Westchester County Dept of Labs

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM iVWm

ate Set: WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 ..(914)593-5575

( - p H NYS-ELAP No. 10108 Fon^-TO (rev. 1/96)

Sample Type (circle one): l^otable 3. Non Potable Treated Bottle Non Potable 4. Other Chain of Custody?___ yes no Time/Date Collected: Comments:____________________________________________ Collected By: C', ~Ts • Agency Code: PWS#;_____ Source ID: Type Descriptor: Collected From: Bill to: Location’s/lndividual’s Name SX Name/Company Street_________________ __ Street________ City/St/Zip_______________ ' City/St/Zip Identification of Source 4 Phone#; Fax#: Collection Point I ca.ch,"bi? Check#; Amounts ~ "

BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS Lab#: (circle tests) - 1. Heterotrophic Plate / . Lab#:__________ _________ ■ (circle tests) 1. Trihalomethanes (524) . f.

_ 1. -Purgeable Halocarbons (624/8260) ' s I'.’j

Count (hernodialysis & all others) ^Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260) 2. Coliform P/A (public supplies) tajvolatile 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 Pesticides (507) 6. PCB’s (Arochlors) (608/8081) 6. roscopic Pesticides/PCB screen (508) 7. Methoprene (616) 7. 8. PCB as Deca'chlorbbiphenyl (508A) 8. Herbicides (EPA1978/8151) 8. Other:____________________ Herbicides (515) 9. Pesticides (SMI 8/6630) Pesticides (525), 10. Petroleum Hydrocarbon Scan (310-13) Refrigerated?yes no 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 (SMI8/6630) 16. Purgeable Aromatics (DEF pH 17. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB’s (DEF) G3 18. Other:__________________________ 18. Other: ,

INORGANIC ANALYSIS REQUESTED - Lab#: I ^1, (circle tests) 1. Color 20. Acidity • 39. Aluminum 59. Potassiurn 2. Turbidity 21. Alkalinity, as CaCOs 40. Antimony 60. Selenium • 3. pH 22. Bromide 41. Arsenic 61. Silver 4. Conddctiyity 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 CaCOa "CLP 9. Chemical Oxygen Demand 28. Nitrogen, Ammonia as N 47. Calcium, Ca*^ 66. Metals/CN V 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^olids, Percent (%) 32. Oil an Grease 51. Copper 70. Disk Deliverables 1|^klids, Settleable 33. Phenol 52. Iron l^^lids. Suspended TCLP 34. Phosphorus Total as P 53.Lead 71 TCLP-Metals 16. Solids, Total 35. Phosphonjs, 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_000071656