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Chain of custody form, Westchester County Labs

Machine-extracted title · confidence 90%

Document tracking the transfer and custody of samples received by Westchester County Department of Labs & Research.

NYC-WTC_000071817–000071824

Folder label: “26315

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Scanned page image, NYC-WTC_000071824
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NYC 9/11 Public Portal Document

SI ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM tester WESTCHESTER COUNTY LABORATORIES AND RESEARCH novwm 2 Dana Road, Valhalla, New York 10595 (914) 593-5575 NYS-ELAP No. 10108 le/Date Set:

Sample Type (circle one): Bottle #’s; d f Q ff 1. Potable 3. Non Potable Treated 2. Non Potable 4. Other____________ Chain of Custody?___ yes___ no Time/Date Collected:: /Of Comments:____________________________________________ Collected By:____ L Agency Code: PWS #:______ Source ID: Type Descriptor: Collected From; Bill to: Location's/lndlvidual’s Name '5 Y Name/Company Street______________________ Street_______ City/St/Zip___________________ City/St/Zip Identification of Source Phone#: Fax#: Collection Point_______ Amounts. CA.CH, Bl? Check#:

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) <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) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8081) 5. Microscopic 6. Pesticides (507) 6. PCB’s (Arochlors) (608/8081) ^^acroscopic (2? Pesticides/PCB screen (508) 7. Methoprene (616) Wpi 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151) 8. Other:________ ____________ Herbicides (515) 9. Pesticides (SMI 8/6630), Refrigerated?yes Chlorinated:? yes___ no no § Pesticides (525) Carbamate Pesticides (531) ■: 12. Glyphosate (547) 10. Petroleum Hydrocarbon Scan (310-13) 11. Glycols 12. Acid Extractables (625/8270) 13. Diquat (549) IX Base Neutral Extractables (625/8270) Free Chlorine Res:. mg/L 14. Chlorination Disinfection Byproducts (551) ^^GC/MS Serriivolatile Unknown Scan total Chlorine Res: 15. Haloacetic Acids (552) 15. Purgeable Halocarbons (DEF) mg/L 16. Pesticides (SM18/6630) 16. Purgeable Aromatics (DEF) pH : 17. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB’s (DEF) 18. Other:_______ ___ ______________ 18. Other: ^.jj IITaWW J

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 CaCOa 46. Calcium, as CaCOa 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 n5. Solids, Suspended 34. Phosphorus Total as P 53.Lead ICkP 71 .TCLP-Metals 16. Solids, Total 35. Phosphorus, Ortho as P 54 Magnesium 55 Manganese ' 72.TCLP-Pesticides 17. Solids, Total Dissolved 36. Sulfates 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

.. __ NYC-WTC_000071824

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NYC-WTC_000071824Source: NYC Law Department, mirrored locally

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