Chain of custody form, Westchester County Labs

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ster WESTCHESTER COUNTY l^BORATORIES AND RESEARCH tn iv.com. 2 Dana Road, Valhalla, New York 10595 ■“ (914)593-5575 - NYS-ELAP No. 10108 l/Date Set;

Sample Type (circle one): - lies-- - Hc, .. Bottle #’s:~^ 'lck'7 » < ; l^otable 3. Non Potable Treated -I 2. Non Potable 4. Other Chain of Custody?yes no Time/Date Collected: /O ' O /_______ / 3 /OV) i-t. Comments: Collected By: i Agency Code; J PWS #: Source ID: Type Descriptor: Collected From: ' Bill to: Location’s/lndividual’s Name "MitVieu W Name/Company street_______________ I_________________ Street_______ City/St/Zip €ity/St/Zip Identification of Source ______________________ 'Phone#; _____ Fax#:’, Collection Point; ----------------- —j—-------- CA,CH, Bl? Check#; Aniount$^

ORGANICPQTABLE ANALYSIS p ORGANIC NONPOTABLE/SOLID ANALYSIS BACTERIOLOGICAL ANALYSIS ' Lab#:__________ \ Lab#: ; ..f (circle tests) (circle teste)" \ 1. Heterotrophic Plate -T- L Trihalomethanes ,(524) 1. Purgeable Halocarbons (624/8260) Count (hemodialysis &"all others) " ^•Wolatile Halocarbons* (524) 2. Purgeable Aromatics (624/8260) 2. Coliform P/A (public supplies) \3^olatile Aromatics (524) 3. Acrolein & Acrylonitrile (624) ' , r-. .- 3. Coliform MPN (priv well, raw,stp) 4. Total Trihalomethane Potential (510) 4. Phthalates (625/8270) i ' 4. Fecal Coliform (all samples) 5. Microextractables 1(504) 5. Organochlorine Pesticides (608/8081) 5. Microscopic 6. Pesticides (507) i; 6. RCB’s (Arochlors) (608/8081) 6^Broscopic ' @ Pesticides/PCB screen (508) 7. Methoprene (616) 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151) tn 8. Other:_________ ___________ Herbicides (515) 9. Pesticides (SMI8/6630) Pesticides (525) 10. Petroleum Hydrocarbon'Scan (310-13) - Refrigerated?yes no ■■ j 11. Carbamate Pesticides (531) 11. Glycols ■ Chlorinated:?yes no 12. qiyphosate (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) ([5? 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. Petroleurh/Hydrocarbon Scan (310-13) 17. Pesticides/PCB’s (DEF) 18. Other: __________________ ___ 18. Other: ___________________

INORGANIC ANALYSIS REQUESTED - Lab#: (circle tests) 1. Color 20. Acidity. ; 39. Aluminum 59. Potassiurp IX! 2. Turbidity 21. Alkalinity, as CaCOa 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 I 6. BOD (5 day) 25. Cyanide 44. Boron 64. VanadiurnI t 7. Soluble BOD (5 day) 26. Fluoride 45. Cadmium 65. Zinc I 8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOs 46. Calcium, as CaCOa CLP 9. Chemical Oxygen Demand 28. Nitrogen, Amrnonia 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/Hexavaient 68. Semi-violatiles 12."Total Organic Halides 31. Nitrogen, Total Kjeldahl as N 50. Cobalt 69. Pesticides/PCB’s l^^olids, Percent (%) 32. Oil ari’Grease 51. Copper 70. Disk Deliverables ■Bblids, Settleable 33. Phenol 52. Iron 15^olids, Suspended 34. Phosphorus Total as P 53.Lead TCLP 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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