Chain of custody form, Westchester County Labs

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM

/Date Set: WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914) 593-5575 / > - SI NYS-ELAP No. 10108 K - _<|.^A-70(rev.1/96)

Sample Type (circle one): r- iLlC I — - .^ j /’‘i^otable 3. Non Potable Treated Bottle #■/* I '2 - -Z-sL?'/. - zf C- CHy___________

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: Location’s/lndividual’s Name. • -HatUiax) Name/Company _ street_________________________________________ Street_________ City/St/Zip_____________________________________ City/St/Zip Identification of Source________________________ ■ -Phone#; Fax#; Collection Point rCA^CIiBITlL Check#; Amount$

BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ' .ORGANIC NONP^TABLE/SOLID ANAlVsIS - Lab#:_______________________ Lab#: (circle tests) (circle tests) 1. Heterotrophic Plate ' Count (hemodialysis & all others) 2. Coliform P/A (public supplies) 1. Trihalomethanes (524) ’ zfA Volatile Halocarbons (524) vsJVolatile Aromatics (524) j 1. Purgeable Halocarbons (624/8260) 2. Purgeable Aromatics (624/8260) 3. Acrolein & Acrylonitrile (624) s 3. Coliform MPN (priv well, raw, stp) 4. Fecal Coliform (all samples) 4. Total Trihalomethane Potential (510) 5. Microextractables (504) *1 4. Phthalates (625/8270) ■ s 5. Organochlorine Pesticides (608/8081) 5. Microscopic 6. Pesticides (507)' ’i 6. PCB’s (Arochlors) (608/8081) 6 roscopic Pesticides/PCB screen (508) '. '7. Methoprene (616) 7 8. Other: S’ PCB as Decachlorobiphenyl (508A) 9- Herbicides (515) 8. Herbicides (EPAI 978/8151) 9. Pesticides (SMI8/6630) >

Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13) o Refrigerated?yes no 11. Carbamate Pesticides (531) 11. Glycols Chlorinated:? yes no 12. Glyphosate (547) ^12. Acid Extractables (625/8270) 13. biquat (549) Base Neutral Extractables (625/8270) Free Chlorine Res:. mg/L 14. 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:. s

INORGANIC ANALYSIS REQUESTED - Lab#: (circle tests) VwE ' 1. Color 20. /'cidity 39. Aluminum 59. Potassium 2. Turbidity 21. Alkalinity, as CaCOa 40. Antimony 60. Selenium 3. pH 4. Conductivity 5. Corrosivity (temp: .®C) 22. Bromide 23. Bromate/Chlorate/Chlorite 24. Chloride ’ 41. Arsenic 42. Barium 43. Beryllium 61. Silver 62. Sodium 63. Thallium pH ' ( 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 CaCOa 46. Calcium, as CaCOa 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.^Tolal Organic Halides 31. Nitrogen, Total Kjeldahl as NI 50. Cobalt 69. Pesticides/PCB’s l^^ilolids, Percent (%) 32. Oil an Grease 51. Copper 70. Disk Deliverables lolids, Settleable 33. Phenol 52. Iron TCLP iolids, Suspended - 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 74. TCLP-Volatiles 19. Other:____________ 38. UV254 57 Molybdenum 75. TCLP-BNA’s 58. Nickel

NYC-WTC_000071738