Chain of custody form, Westchester County Dept of Labs

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION EpRM p& ffisl^ester • WESTCHESTER COUNTV L’ABpRATORIES AND RESEARCH * | «^^gov.com 2 Dana Road, Valhalla, New York 10595' (914) 593-5575 RE ’f'-' f^S^LAP No. 10108 • le/Date Set: ■orm A-70 (rev. 1/96)--*-

SampJeType (circle one): "W f j)p6table 3. Non Potable Treated Bottle #’s: 2. Non Potable 4. Other ' . Chain of Custody?___ yes no - ' Time/Date Collected: _ Comments: Collected By: _ Agency Code: PWS #:______ Source ID: Type Descriptor: Collected From: Bill to: AJ V C bg P /O Location’s/lndividual’s Name Name/Company street '(Street_______ City/St/Zip > AJV 'City/St/Zip Identification of Source■ Phone#: Fax#: 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'Halocarbdns (624/8260) Count (hemodialysis & all others) /2.'\ Volatile Halocarbons (524) ) 2...Purgeable Aromatics (624/8260) 2. Coliform P/A (public supplies) kg,/Volatile Aromatics (524) ? 3.' Acrolein & Acrylonitrile (624) 3. Coliform MPN (privwell, raw,stp) 4. -Total Trihalomethane Potential (510) ’ . . V 4. Phthalates (625/8270).. . \ 4. Fecal Coliform (all samples) 5/ Microextractables (504) Y 5. Organochlorine Pesticides (608/8081) . 5.'Microscopic ,/ ' ,6.. Pesticides’ (507) 6. PCB’s (Arochlors), (608/8081) . ^^Macroscopic Q Pesticidds/PCB' screeri (508) 7. Methoprene (616) . 8. PCB as. Decachlorobiphenyl (508A). 8. Herbicides (EPAI 978/8151) Sather: ’9. Herbicides.(515)' 9. . Pesticides (SMI 8/6630) Pesticides (525) 10.'Petroleum Hydrocarbon Scan (310-13) Pefrigerated? yes___ no Tt 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 Unknbwri 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: ;.' INORGANIC ANALYSIS REQUESTED - Lab#: I

(circle tests) • ' ' fWlio 1. Color 20. Acidity ,, ^^^Aluminum I P SS^UldSSiuiii '" " 2. Turbidity 21. Alkalinity, as CaCOs ^jj?Ahlii 1 luoy '’""60? Seleriium 3. pH ■ 22. Bromide V ■/ 4l/Ar?erfio' 61^ Silver 4. Conductivity . ..23. Bromate/Chlorate/Chlorite >'r''‘Y-42..Barium ^/^O^Oodium— 5. Corrosivity (temp:_____ ®C) 24. Chloride *, ' ' ^„48TBbiyllluiii les.'lTiiaiiidlii -.6. BOD (5 day) 25. Cyanide 44. Boron ' 7. Soluble BOD (5 day) - 26'.■'Fluoride 45. Cadmium 65. Zinc 8'. Carbonaceous BOD (5 day) • ' 27. Hardness, Total as CaCOs Calcium,-as CaCOa CLP 9. Chemical Oxygen DemandI 28. Nitrogen, Ammonia as N 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 4§^Chromium, Hexavalent 68. Semi-violatiles ’ 31. Nitrpge.n', Total Kjeldahl as.N ' fcS^Cobalt’ , 69. Pesticides/PCB’s 12.notal Organic Halides ■13. Solids, Percent (%) ■ ’32.‘Oil an'jGrease.. ’ 70. Disk Deliverables --33. Pheiiof:^ - ' iT '- ^^Solids,. Settleable ■ TCLP wFsolids, Suspended * . . 34,'PhospferusTotalasP ..^/Lead. 71.TCLP.-Metals. . ’ .16. Solids, Total . ■J . ,35.' Phosphorus; Ortho as P 72.TCLP-Pesticides, "T" ■ . .-"36‘Siilt^^-f ■' V55 Manganese , 17. Solids, Total Dissolved ,' ' 73.TCLP-Herbicides 37.'Surfa6tants. ' \ > . 5a Mercury,, '■ V', 74.'TCLP-VoiatiTes '' '75.'TCLP-BNA’s' J, . '.ii .

NYC-WTC_000071716