Chain of custody form, Westchester County Dept of Labs

NYC 9/11 Public Portal Document

■ ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM L WVCOm

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

C - z • H NYS-ELAP No. 10108 y .;Form A-70 (rev. 1/96)

Sample Type (circle one): l/Potable I3. Non Potable Treated Bottle #’'s: '2 <9 2. Non Potable 4. Other____________ Chain of Custody?___ yes no Time/Date Collected: A-- Comments:__________________ Collected By: Agency Code: PWS #:____ __ Source ID: Type Descriptor: Collected From: Bill to: Location’s/lndividual’s Name (ha IJ ft yj Name/Company Street____________________ Street________ City/St/Zip________________ City/St/Zip Identification of Source ' ■> Phone#; Fax#: Collection Point _ b/ Tca,ch. bi?< Check#: AmountSji

BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS organic' NONPOTABLE/SOMP ANALYSIS Lab#:____ Lab#;___________ '_______ _ (circle tests) (circle tests) \ » 1. Heterotrophic Plate 1. Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260) Count (hemodialysis & all others) Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260) 2. Coliform P/A. (public supplies) ka? Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624) 3. Coliform MPN (privwell, 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.i.microscopic Pesticides/PCB screen (508) 7. Methoprene (616) 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151) !. OTher: & Herbicides (515) 9. Pesticides (SMI8/6630) V 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) <35 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:______________ L

INORGANIC ANALYSIS REQUESTED - Lab#: (circle tests) i 1. Color 20. Acidity 39. Aluminum 59. Potassium 2. Turbidity 21. Alkalinity, as CaCOs 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 /\ 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 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 l4^lids. Settleable 33. Phenol 52. Iron iSKlids, 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. TCLP-Herbicides 18. Solids, Total Volatile 37. Surfactants 56. Mercury 57 Molybdenum 74. TCLP-Volatiles 19. Other:_________________ 38. UV254 58. Nickel . 75. TCLP-BNA’s

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