Chain of custody form, Westchester County Labs

NYC 9/11 Public Portal Document ‘ ■ -•.'XU

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM

r__ s ^^/Date Set: sster Dv.com WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914) 593-5575 SI NYS-ELAP No. 10108 Form A-70 (rev.1/96)

Sample Type (circle one): J.Notable 3. Non Potable Treated Bottle #’s: ' d 4 Z 2. Non Potable 4. Other / _________________________ Chain of Custody? yes___ no Time/Date Collected:. I Zt L> Comments: Collected By: Agency Code: PWS #:________ Source ID: Type Descriptor: Collected From: Xr/f Bill to: Location’s/lndividuars Name Name/Company Street_________ __ Street_________ City/St/Zip__________ City/St/Zip Identification of Source'. Phone#:_______ Fax#: Collection Point I CA.CH, Bl? Check#: Amounts .

BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLIO ANALYSIS Lab#:' Lab#:_________________ ' (circle tests) (circle testsj^ 1. Heterotrophic Plate 1. Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260) Count (hemodialysis & all others) >2^ Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260) 2. Coliform P/A (public supplies) \aJ 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. Pesticides (507) 6. PCB’s (Arochlors) (608/8081) • roscopic 0 Pesticides/PCB screen (508) 7. Methoprene (616) 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPAI 978/8151) 8. Other: j____________________ a Herbicides (515) . . 9. Pesticides (SMI8/6630) 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) ^GC/MS Semivolatile Unknown 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#: (circle tests) 1. Color 20. Acidity 39. Aluminum MX 59. Potassium 2. Turbidity 21. Alkalinity, as CaCOs 40. Antimony 60. Selenium i 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 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 ^B|olids, Settleable 33. Phenol, ' 52. Iron l^^olids. Suspended 34. Phosphorus Total as P 53.Lead TCLP 71 TCLP-Metals 16. Solids, Total 35. Phosphorus, Ortho as P 54 Magnesium 36. Sulfates?' 55 Manganese 72.TCLP-Pesticides 17. Solids, Total Dissolved 56. Mercury 73.TCLP-Herbicides 18. Solids, Total Volatile 37. Surfactants 57 Molybdenum 74. TCLP-Volatiles 19. Other:_________________ 38. UV254 58. Nickel 75. TCLP-BNA’s

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