Chain of custody form, Westchester County Dept of Labs

NYC 9/11 Public Portal Document

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

Sample Type (circle one): fT^otable 3. Non Potable Treated 2. Non Potable 4. Other__________________________ Chain of Custody? yes___ no Time/Date Collected: ________ U-2^ Comments: Collected By: 1 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 fV * Phone#;_______ Fax#: Collection Point f L| U (9 CA,CH,BI? Check#: ? Amounts.

BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ' - ORGANIC NONPOTABLE/SOLID ANALYSIS Lab#: ■■ ' ■ ■ ! t Lab#:______________ ________ (circle tests) (circle tests) 1. Heterotrophic Plate 1.. Trihalomethanes (524) . . - T.- Purgeable Halocarbons" (624/8260) Count (hemodialysis & all others) '^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 (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 ( 7.' Pesticides/PCB screen (508) 7. Methoprene (616) .r 7. '8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151) 8. ^^r: 9,^ Herbicides (515) 9. Pesticides (SMI 8/6630) Refrigerated?yes no Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13) • • 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) (l4yGC/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) 18. Other:__________________________ 18. Other;__________________________

INORGANIC ANALYSIS REQUESTED - Lab#: 39. Alurninum | >-L5 (circle tests) KJ =-'5 1. Color 20. A:idity 59. Potassium 2. Turbidity 21. Alkalinity, as CaCOs 40. Antimony 60. Selenium; 3. pH 22. Bromide 41. Arsenic 61. Silver ; 4. Conductivity 5. Corrosivity (temp: 6. BOD (5 day) .®C) 23. Bromate/Chlorate/Chlorite 24. Chloride 25. Cyanide 26. Fluoride 42. Barium 43. Beryllium 44. Boron 45. Cadmium 62. Sodium ■ 63. Thallium 64. Vanadium 4 7. Soluble BOD (5 day) 65. Zinc 8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOa 46. Calcium, as CaCOs 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 l^olids. Settleable 33. Phenol 52. Iron l^^lids. Suspended 34. Phosphorus Total as P 53.Lead T£kE 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

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