Chain of custody form, Westchester County Labs

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM

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

Sample Type (circle one): Potable 3. Non Potable Treated Bottle #’s: __ _________ __________________________________ 2. Non Potable 4. Other Chain of Custody?___ yes no , Time/Date Collected: / Comments:_______ ____________________________ _ _______ Collected By: C » J iJ Agency Code: PWS#;______ Source ID: Type Descriptor Collected From: Bill to: Location’s/lndividual’s Name S J- Name/Company Street_________________________ Street_______ City/St/Zip _ ____________________ City/St/Zip Identification of Source__ 2_________ Phone#; Fax#: Collection Pqint »» I CA,CH, Bl? Check#;' Amounts ■

BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS Lab#;____________________ __ Lab#:________________________ (circle tests) (circle tests) 1. Heterotrophic Plate L Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260) Count (hemodialysis & all others) Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260) 2. Coliform P/A (public supplies) \3/ 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)

w 5. Microextractables (504) 5. Organochlorine Pesticides (608/8081) 5. Microscopic 6. Pesticides (507) 6. PCB’s (Arochlors) (608/8081) roscopic Pesticides/PCB screen (508) 7. Methoprene (616) PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151) 8. Other:____________________ Herbicides (515) 9. Pesticides (SMI 8/6630) ® Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-1S)": Refrigerated?yes no 11. Carbamate Pesticides (531) 11. Glycols ’ Chlorinated:? yes no 12. Glyphosate (547) 12. Acid Extractables (625/8270) c- 13. Diquat (549) 13. Base Neutral Extractables (625/8270) Free Chlorine Res:. mg/L 14. Chlorination Disinfection Byproducts (551) (i^pGC/MS Semivolatile Unknown Scan Total Chlorine Res: mg/L 15. Haloacetic’Acids (552) 15. Purgeable Halocarbons (DEF) 16. Pesticides (SM18/6630) 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) I c.j- 1. Color 20. Acidity 39. Aluminum 59. Potassiurri 2. Turbidity 21. Alkalinity, as CaCOa 40. Antimony 60. Selenium j. tn 3. pH 22. Bromide 41. Arsenic 61. Silver 42. Barium 4. Conductivity 5. Corrosivity (temp: ' 6. BOD (5 day) °C) 23. Bromate/Chlorate/Chlorite 24. Chloride 25. Cyanide 43. Beryllium 44. Boron 62. Sodium 63. Thallium 64. Vanadium Um 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 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 NI 50. Cobalt 69. Pesticides/PCB’s 13_Solids, Percent (%) . 32. Oil an Grease 51. Copper 70. Disk Deliverables I^nlids, Settleable 33. Phenol 52. Iron ICLP I^TColids, 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

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