Chain of custody form, Westchester County Dept of Labs

NYC 9/11 Public Portal Document Yt’.' ■■ - - ■ r-' . ... • ; -

ENVIRONMENTALSERVICESSAMPLESUBMISSIONFpRM ... ster WESTCHESTER COUNTY LABORATORIES:AND RESEARCH J >v.com 2 Dana Road, Valhalla? New York 10595 . (914)593-5575 *• NYS-ELAP No. 10108 le/Date Set: Form A-70 (rev. 1/96)

Sample Type (circle one): Potable 3. Non Potable Treated Bo«e,s: , 2. Non Potable' 4. Other .- Chain of Custody? yes no Tlme/Date.Coll^:'^^,^ Comments: Collected By;___________ - Agency Code: PWS #:______ Source ID: Type Descriptor: Bill to: Name Name/Company _ Street / r iVrtr Street_________ city/st^JZ^I^E?ZZrz5EZZZZZ Y City/St/Zip Identification of Source -x - •______________________ ^Phone#: Fax#: Oc L- Collection Point________________________________________ CA.CH, Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID 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) Volatile. Aromatjcs_(524) . 3. Acrolein.& Acrylonitrile. (624) 3. Coliform MPN (priv well, raw.stp) 4. Total. Tritiaiom^hane Potential (510) 4. Phthalates (625/8270) 4. , Fecal Coliform (all samples) .5. Micr6extractables'(504) , 5. Organochlorine Pesticides (608/8081) 5'. Microscopjc 6. Pesticides (507)_ 6.’ PCB’s, (Arochlors) (608/8081) ^^croscopic Pesticides/PCB screen (508) ; 7...Methoprene.(616) 8. PCB as’Decachlo'robiphenyl (508A) S'f Herbicides (EPAI 978/8151)' ^ther?____________ _ Herbicides (515) ' . 9. Pesticides (SMI 8/6630)' (10/ Pesticides (525) ' ' tr- 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) 1 13, Diquat'(549)'’ ' 13. Base Neutral Extractables (625/8270) Free Chlorine Res: mg/L it. 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) 18. Other:- ' ' > ________ 18. Other:__________________ "

INORGANIC ANALYSIS REQUESTED - Lab#: (circle tests) 1. Color 20. Acidity ; Aluminum m-iW' '^59. Potassium ■' • 2. Turbidity 21 . Alkalinity, as CaCOs Antimony 60. Selenium .. ■ 3.' pH 22. Bromide 41. Arsenic ^61. Silver 4. Conductivity 23. Brornate/Chlorate/Chlorite ■4&. Barium { 6^ Sodium 5.. Corrosivity (temp:®C) 24. Chloride • ' -43. Beryllium I 631 Thallium 6. BOD (5 day) 25. Cyariide -■ 44. Boron '*-64. Vanadium 7. Soluble BOD (5 day) 26.'Fluorid.e ’ - 45. Cadmium 65. Zinc 8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOs (^4-6. Calciurn, as CaCOs CLP 9. Chemical Oxygen Demarid 28. Nitrogen,'Ammonia aslNJ' .C^cijumVCa 1® 66. Metals/CN 10. Dissolved Oxygen, 29.' Nitrogen, Nitrate as N 48. Chromium',' Totaii' 67. Volatiles 11. Total Organic Carbon 30. Nitrogen, Nitrite as N Chromium,^ Hexavalent 68. Semi-violatiles'’ 12.-Total Organic Halides 31 .*■ Nitrogen','Total Kjeldahl as' ty.— s'o.Cobalt '” j ” 69. Pesticides/PCB’s '13. Solids,‘'Percent (%) 32.iOir.amGrease, • Z^/Copper,' 70. Disk Deliverables ' ’ ASolids, Settle'able. 33,.Phenq^ ^.-Iron} tcLp. Solids, Suspended 34. Phosphorus Totaras'P?_ y-MXeadJ . . 35;rPh'b's'ph6rus'; O.rtFi^ f ^sMagn'esium’ _ 71.TCLP-Metalsj -16?S6licis',',Totall 72;TC'LP~Pesticides; : 17. Solids, TotatDissolved 36. Sulfates ’ ' ■ \^^M^ganese>. , 37'<Su"rfactants ■ ... , .s \ /-^.'Mercuityt.. ;73.TCLP-Herbicides., 8/ Solicls; Total ,V^tile • - 74:’TCLP-Yolatiles, ■M'g.^bthej':-. ' 38-;UV254?‘ • ■ ^^.•'MolybtdefiurTi.. - '75.’TCLP-BNA’s'-' ■ .587Nicl<eli ■* "; ‘ f ■ ' — J .... NYC-WTC_000071714