Chain of custody form, Westchester County Dept of Labs

NYC 9/11 Public Portal Document

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f/Date Set: ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914)593-5575 nr NYS-ELAP No. 10108 Form A-70 (rev. 1/96)

Sample Type (circle one): V. « x-vc- . 'i 'IO

1. Potable 3. Non Potable Treated Bottle rs: «^.-3r-L 2. Non Potable 4. Other __ _________ Chain of Custody? ___ yei Time/Date Collected: I C / 7?)/7Oo/ llu Commjpnts: Collected Agency Code: PWS #: ___i_ Source ID:----- C^J^Tyfe^e^iptcjr^j^

Collected From: Bill to: Location’s/lndividual’s Name _ Name/Company Street____________________ Street ‘ Citv/St/Zio City/St/Zip,____ Identification of Source ~ ♦ btp'^ Phone#: - * Fax#: Collection Point _L2_hLSZy. — cA.CH?BI?^ Check#: Amount$ 1 .

BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID,ANALYSIS Lab#: ; Lab#:‘ - I- . . (circle tests) (circle tests), 1. Heterotrophic Plate 1. Trihalomethanes'(524) - - T. 'Purgeable Halocarbons (624/8260) Count (hemodialysis & all others) /S Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260) ■g 2. Coliform P/A (public supplies) La? 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) ^12 5. Microscopic a Pesticides (507) 6. PCB’s (Arochlors) (608/8081) 6.J|^roscopic (7) Pesticides/PCB screen (508) 7. Methbprene (616) > 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPAI 978/8151) j,:, 8. felltier: 9.. Herbicides (515) 9. Pesticides (SMI8/6630) Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13)52 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) (1^ GC/MS Semivolatile Unknown Scan Total Chlorine Res: mg/L 15. Haloacetic Acids (552) 1'5. Purgeable Halocarbons (DEF) 16. Pesticides (SMI8/6630) 16. Purgeable Aromatics (DEF) pH 17. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB's (DEF) 18. Other:__________________________ 18. Other:,i-

INORGANIC ANALYSIS REQUESTED - Lab#: (circle tests) 1. Color 20. Acidity O tlbd.. 39. Aluminum 59. Potassium 2. Turbidity^ 21. Alkalinity, as CaCOa 40. Antimony 60. Selenium’ 3. pH • / 22. Bromide 41. Arsenic 61. Silver S 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 3? 45. Cadmium 65. Zinc / 8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOs 46. Calcium, as CaCOs GLE //, 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 l^^lids. Settleable 33. Phenol 52. Iron iWRjIids, Suspended TCLP 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. TCl^-Herbicides 18. Solids, Total Volatile 37. Surfactants 56. Mercury 74. TCLF-\^atiles 19. Other:_________________ 38. UV254 ■ 57 Molybdenum 75. TCLP-BNA's 58. Nickel

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