Chain of custody form, Westchester County Labs

NYC 9/11 Public Portal Document

L ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM )V.mm WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla. New York 10595 (914) 593-5575 NYS-ELAP No. 10108 ^^/Date Set: Form A-70 (rev. 1/96) 1/ Sample Type (circle one); ^Potable 3. Non Potable Treated Bottle rs: 2. Non Potable 4. Other____________ Chain of Custody?___ yes no Time/Date Collected: /q/2 H‘^r) Comments:__________________ Collected By:______ 'C--; ■' Agency Code: PWS #:______ Source ID: Type Descriptor: Collected From: Bill to: Location’s/lndividual’s Name ■err Name/Company Street_____________________________________ .________ Street_______ City/St/Zip ____________________________ _______________ City/St/Zip Identification of Source __l_ b tP Phone#: Fax#: Collection Point__ I CA,CH, Bl? Check#: Amounts>

BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS Lab#: _______________ Lab#:________________________ (circle tests) (circle tests) 1. Heterotrophic Plate . 1. Trihalometharies (524) 1. Purgeable Halocarbons (624/8260) Count (hemodialysis & all others) Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260) 2. Coliform P/A (public supplies) ■U3/ Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624) 3. Coliform MPN (priv well, raw, stp) 4. Total Trihalomethane Potential (510) 4. Phthalates (625/8270) 4. Fecal Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8081) 5. Microscopic 6 roscopic 6. Pesticides (507) 6. PCB’s (Arochlors) (608/8081) S Pesticides/PCB screen (508) 7. Methoprene (616) 7 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151) 8. Other: 9. Herbicides (515) 9. Pesticides (SM18/6630) >• Refrigerated?yes no Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13) 11. 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) ;14z 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 39. Aluminum 59. Potassium cs? — ■< c;:3 2. Turbidity 21. Alkalinity, as CaCOs 40. Antimony 60. Seleniurn 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 \ 6. BOD (5 day) 25. Cyanide 44. Boron 64. Vanadium 7. Soluble BOD (5 day) 26. Fluoride 45. Cadmium 65. Zinc J 8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOa 46. Calcium, as CaCOs 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."Total Organic Halides 31. Nitrogen, Total Kjeldahl as N 50. Cobalt 69. Pesticides/PCB’s l^^olids. Percent (%) 32. Oil an Grease 51. Copper 70. Disk Deliverables I^^Blids, Settleable 33. Phenol 52. Iron l^^olids. 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 57 Molybdenum 74. TCLP-Volatiles 19. Other:_________________ 38. UV254 75. TCLP-BNA’s 58. Nickel

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