Chain of custody form, Westchester County Labs

NYC 9/11 Public Portal Document

H ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM RI ster WESTCHESTER COUNTY LABORATORIES AND RESEARCH iv.com 2 Dana Road, Valhalla, New York 10595 (914) 593-5575 NYS-ELAP No. 10108 /Date Set: Form A-70 (rev. 1/96) S' B Sample type (circle one): 1. Potable 3. Non Potable Treated Bottle #’s: ' A x 2. Non Potable 4. Other Chain of Custody?___ yes __ no Time/Date Collected; Xts. .-q \ 0^ Comments: Collected'By:" 'U'A (.A 7, Agency Code: PWS #:______ Source ID: Type Descriptor: Collected From: Bill to: Location’s/lndiyidual’s Name Name/Company Street _ ______________ Street_______ City/St/Zip . ' - ■ City/St/Zip Identification of Source 1 Phone#: Fax#: CQllectfon Point $ “■i I CA.CH, Bl? Check#; Amounts.

BACTERIOL^ICAL ANALYSIS ' . ORGANIC POTABI^ ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS Lab#: ; - ' - • Lab#;_______ ________________ (cirCte^ts)T • (circle tests) 1. Heterotrophic Plate''; ,, , 1. Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260) Courit' (hemodialysis & all 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 . (privwell, raw,stp) 4. Total Trihalomethane Potential (510) 4. Phthalates (625/8270) 4. Faecal Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8081) • 5. Microscopic ' 6. Pesticides (507) 6. PCB’s (Arochlors) (608/8081) 6^^^roscopic Pesticides/PCB screen (508) 7. Methoprene (616) K PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151) 8. Other:_____________________ 9. Herbicides (515) 9. Pesticides (SM18/6630) > (1^ Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13); Refrigerated?yes no 11. Carbamate Pesticides (531) 11. Glycols Chlorinated:? yes___ no 12. Glyphosate (547) 12. Acid Extractables (625/8270) 13. Diquat (549) J3. Base Neutral Extractables (625/8270) Free Chlorine Res:. mg/L 14. Chlorination Disinfection Byproducts (551) tU? GC/MS Semivolatile Unknown Scan Total Chlorine Res: ■ mq/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 2. Turbidity 21. Alkalinity, as CaCOs 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 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 CaCOs 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."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 "^Bolids, Settleable 33. Phenol 52. Iron l^^olids. Suspended TCLP 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

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