Chain of custody form, Westchester County Dept of Labs

NYC 9/11 Public Portal Document

, ENVIRONMENTAL SERVICES SAMPLE SUBMISSlbN gORM; P; 2U -WESfCHESTER COUNTY LABORAtORIES AND'rESEARCH^ 2 Dana Road, Valhalla, New York 10595 (914)593-5575 ' 'S-ELAPNo. 10108 ' le/Date Set: 'Q Form A-70 (rev.1/96)—~

Sample Type (circle one): Quotable 3. Non Potable Treated

2. Non Potable 4. Other_____________ ■ Chain of Custody?yes ___ no Time/Date Collected: _ Comments:____________ Collected By: Afgw/M a/ Agency Code: PWS #: Source ID: Type Descriptor: Collected From: , zn / Bill to: Location’s/lndividual’s Name _C hg K /^.gA)Sx:C^ Name/Company________________ Street Vy/fe-r 1^, ________ Street________________________ City/St/Zip _ \lALklAiiA > A/y City/St/Zip____________________ Identification of Source____________ ;______________________ Phone#:______________________ Fax#: Collection Point _ 4/^^^______________ 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 & ail others) Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260) ' ■, 2. Coliform P/A .(public supplies) Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624) 3. Coliform MPN (priv well, raw. stp) 4^ Total Trihalomethane Potential (510) 4. Phthalates (b5/827o'j • ■ 4. Fecal Coliform (all samples) .5? Microextractables (504) 5. Organochlorine Pesticides (608/8081) 5.' Microscopic 6. Pestjcides JSO?) 6. PCB’s (Arochlors) ,(608/8081) .' ' ^^acroscopic Peslicides/PCB screen (508) \ .7. Methoprene (61'6) 8.; PCB as Deca’chlorobiphenyl (508A) ‘ ■ 8.'Herbicides (EPAl 9'78/8151) Sather: . 9; 'Herbicides’(515)' ' .9. Pesticides ;(SMi8/6630) Pesticides (525) ;! 10. Petroleum Hydrocarbon Scan (310-13) Refrigerated? yes no n. 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 7(551) y^GC/MS Semiv'olatile Unknown Scan • 15. Haloacetic Acids (552) 15. Purgeable Halocarbons (DEF) Total Chlorine Res: _______ mg/L 16. Pesticides (SM18/6630) . 16. Purgeable Aromatics (DEF) pH __ '17. Petroleum/Hydrocarbon Scan (310-13).^ 17. Pesticides/PCB’s (DEF) 18. Other: * 4 18. Other;

INORGANIC ANALYSIS REQUESTeB - Lab#: (circle tests) ■ V;..t 5 *S - ‘ '

1. Color 2O.Acidity. Si^Aluminum —^sa^jPotassiure— / 2. Turbidity 21. Alkalinity, as CaCOs ( 'Bb. Selenium 3. pH 22. Bromide ... “41.Arsenic 61. Silver 4. Conductivity 23. Brorhate/Chlorate/Chlorite ^>Barium ^2)-6odium ■ 5. Corrosivity (temp:’C) 24. Chloride TtSTBerytttwFb— rOO.jTliuIliuir* 6. BOD (5 day) 25. Cyanide 44. Boron' 7. Soluble BOD (5 day) 26. Fluoride 45.Cadmiur5 65. Zinc 8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOs ^46.^palcium?as CaCOs CLP 28. Nitrogen, Ammonia as N \.4ZrbaiGiUnU Ca . 66. Metals/CN •- 9. Chemical Oxygen Demand 10. Dissolved Oxygen 29. Nitrogen'; Nitrate as N . ■ 48.Chromiijm', Total • . , 67. Volatiles ‘ 11. Total Organic'Carbon 30. Nitrogen, Nitrite as N 49’chromi'um, Hexavalent - c. 68. Serni-violatiles 12.^Total Organic Halides 31. Nitrogen^-Total.Kjeldahl as N/ . 69. Pesticides/PCB’s • 13. Solids? Percent"' (%) 32. Oil an'Grease ' 5^ Copper. . ? , 70?Disk"Deliverables ^^^Solids, Settleable 33. Phenpl'y- ; ■ , . $ WrSolids, Suspended 34. Phosphorus Total as P ' ^:Leady , f fcLp> < • 7,3 .TGLP-Metals. 16. Solids. Total ' 35. Phosptiprus, Ortho as P ’• 'i^54'MJfI^et>luiii 36. Sulfates * n ( 5^ariganese' ' 72.TCLP-Pesticides. 17.,Solids, Total Dissolved' yTs.-TCLI^-Herbicides ■ 18. 'SoHds? f6tal..Vol’atjie'; . 37;-Surfacta'nts ’ . ' ' ,56’Mercury.-' 74? -TCLP:Volatiles; .; Ag^fher:; • 38..uy25,4j ' •- " - ' ■ , M^Nickeli 75;TCLP-BNA ’S'

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