Chain of custody form, Westchester County Labs

NYC 9/11 Public Portal Document

ester Environmental services sample submission form WESTCHESTER COUNTY LABORATORIES AND RESEARCH I ITovcom 2 Dana Road, Valhalla, New York 10595 (914) 593-5575 .NYS-ELAP No. 10108 Date Set: / Form A-70 (rev. 1/96) /’J' > > . / r? i> Z t- z 'z ■? Sample type (circle one): ^^otable 3. Non Potable Treated Bottle #’s:zr±±i2:£2ijLrirj^_____ 2. Non Potable 4. Other Chain of Custody?___ yes no Tlme/Date Collected: Comments: Collected By: C- TVt/r Agency Code: PWS #:______ Source ID: Type Descriptor: Collected From: Bill to: Location’s/lndividual’s Name SJ. Name/Company Street_________________ Street_______ City/St/Zip______________ City/St/Zip Identification of Source Phone#: Fa^: Collection Point_____ (T CA,CH, Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS Lab#:_______________________ Lab#:________________________ (circle tests) (circle tests) 1. Heterotrophic Plate ‘ 1. 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) (4,; 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) l^^croscopic Pesticides/PCB screen (508) 7. Methoprene (616) 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPAI 978/8151) 8. Other:__________________ __ Herbicides (515) 9. Pesticides (SMI 8/6630) Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13) Refrigerated? yes no 11. Carbamate Pesticides (531) 11. Glycols Chlonnated:? yes___ no 12. Glyphosate (547) 12. Acid Extractables (625/8270) 13. Diquat (549) ia Base Neutral Extractables (625/8270) Ff^e Chlorine Res:. mg/L . ^^GC/MS Semivolatile Unknown Scan 14. Chlorination Disinfection Byproducts (551) Total Chlorine Res: '15. Haloacetic Acids (552) 15. Purgeable Halocarbons (DEF) q6. Pesticides (SMI 8/6630) 16. Purgeable Aromatics (DEF) dH- . , I. 1'7. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB’s (DEF) 18,..Other. 18. Other: _____________________ ;

INORGANIC ANALYSIS REQUESTED - Lab#: (circle tests) 1. Color ’8 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 X 2d. 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 CaCOa 46. Calcium, as CaCOs £t£ 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 ia Solids, Percent (%) 32. Oil an Grease 51.Copper 70. Disk Deliverables ^MSolids, Settleable 33. Phenol 52. Iron ^^Solids, Suspended 34. Phosphorus Total as P 53.Lead ICL£ 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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