Chain of custody form, Westchester County Dept of Labs

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM

• Date Set: )VOOm WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914) 593-5575 B NYS-ELAP No. 10108 ^orm A-70 (rev. 1/96) ■■

Sample Type (circle one): . 1. Potable 3. Non Potable Treated 2. Non Potable 4. Other / ,______ 5* d v-* Chain of Custody?yes,no Time/Date Collected: V Comments: Collected By: 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 S J I CA.CH, Bl? Check#: • Amount$l

BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS* ORGANIC NONPOTABLE/SOLIDANALYSIS Lab#: ________ _______ liib#;_^_________ __________ (circle tests) (circle tests) 1. Heterotrophic Plate i Trihalomethanes (524) ' T. Purgeable Halocarbons (624/8260) Count (hemodialysis & all others) 7 2.) Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260) 2. Coliform P/A (public supplies) <3/ Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624) 3. Coliform MPN (privwell, raw,stp) •r > 4. Total Trihalomethane Potential (510) 4. Phthalates (625/8270) 4. Fecal Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8081) 1 5. Microscopic Pesticides (507) 6. PCB’s (Arochlors) (608/8081) 6.J|^roscopic d? Pesticides/PCB screen (508) 8. PCB as Decachlorobiphenyl (508A) 7. Methoprene (616) 8. Herbicides (EPAI 978/8151) 8. Other:____________________ ^.Herbicides (515) 9. Pesticides (SMI8/6630) ;> Qy Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13). Refrigerated? yes no 11. Carbamate Pesticides (531) 11. Glycols Chlorinated:? yes___ no 12. Glyphosate (547) 12. Acid Extractables (625/8270) ;; 13. Diquat (549) 13L 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 (SMI 8/6630) 16. Purgeable Aromatics (DEF) pH 17. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB’s (DEF) 18. Other:__________________________ 18. Other:.

INORGANIC ANALYSIS REQUESTED - Lab#: (circle tests) 51= 39. Aluminum I 1. Color 20. Acidity 59. Potassiurn is: 2. Turbidity 21. Alkalinity, as CaCOa 40. Antimony 60. Selenium | 3. pH 22. Bromide 41. Arsenic 61. Silver | 4. Conductivity 23. Bromate/Chlorate/Chlorite 42. Barium 62. Sodium 5. Corrosivity (temp: .®C) 24. Chloride 43. Beryllium 63. Thallium I- 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 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 iM^lids, Settleable 33. Phenol 52. Iron TCLP iWcolids, Suspended 34. Phosphorus Total as P 53.Lead 71 TCLP-Metals 16. 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_000071658