Chain of custody form, Westchester County Labs

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914) 593-5575 '"’ nYS-ELAP No. 10108 le/Date Set: Form A-70 (rev. 1/96) / Sample Type (circle one): 1 .'Potable :3, Non Potable Treated Bottle #'s: 2. Non Potable 4, Other____________ Chain of Custody? yes no Time/Date Collected:: f C f < ■ I im. Comments: Collected By: r ■ < V.l Agency Code: PWS #:________ Source ID: Type Descriptor: Collected From: Bill to: Location’s/lndividual’s Name Name/Company _ Street_____ ____ ______________ Street_________ City/St/Zip_____________________ City/St/Zip Identification of Source Phone#:_______ Fax#: Collection Point/ / CA,CH, Bl? Check#; Amounts.

BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS Lab#:______________________ Lab#:______________________ (circle tests) (circle tests) 1. Heterotrophic Plate Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260) Coynt (hemodialysis & all others) , Volatile Halocarbons (524) '2. Purgeable Aromatics (624/8260) ‘2. Coliform P/A (public supplies) Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624) jS/ Coliform M PN (priv well, raw, stp) 4. Total Trihalomethane Potential (510) 4. Phthalates (625/8270) .i'A^'^dcal Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8081) 6. Pesticides (507) 6. PCB’s (Arochlors) (608/8081) ^■jdacroscopic Pesticides/PCB screen (508) 7. Methoprene (616) PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPAI 978/8151) Herbicides (515) 9. Pesticides (SM18/6630) (y Pesticides ^51 10. Petroleum Hydrocarbon Scan (310-13) ^Refrigerated?, .^11. CarbarnateS|« 11.: Chlorinated:?_ L_ 12. Glyphosate'S^ . Acid Extractables (625/8270) 13. Diquat (549)>i, ’ 13. Base Neutral Extractables -(625/8270) Free Chlorine Res:. mg/U' 14. Chlorination D&rifpction Byproducts (551) (14^C/MS Semivolatile Unknown Scan •jp. f l'' 15. Haloacetic Acids *^52) tST Purgeable Halocarbons (DEF) Total Chlorine Res;' < .■mg/L t' 16. Pesticides (SMI 8/6630) 16. Purgeable Aromatics (DEF) 17. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB’s (DEF) -‘l8. 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 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 ^3; Solids, Percent (%) 32. Oil an Grease 51. Copper 70. Disk Deliverables Solids, Settleable 33. Phenol 52. Iron 53.Lead TCUP Solids, Suspended 34. Phosphorus Total as P 71 TCLP-Metals 16. Solids, Total 35. Phosphorus, Ortho as P 54 Magnesium , 72.TCLP-Pesticides 17. Solids, Total Delved 36. Sulfates 55 Manganese 73. TCLP-Herbicides 18. Solids, Total Vr^ile ' ' 37. Surfactants ' W - 56. Mercury 74. TCLP-Volatiles 19.'Other: ________________ 38. UV254 '* ■ 57 Molybdenum 75.TCLP-BNA’s 58. Nickel

NYC-WTC_000071822