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 ^^/Date Set: NYS-ELAP No. 10108 Form A-70 (rev. 1/96) 7^77 Sample Type (circle one): ^l^otable 3. Non Potable Treated <’ 9-^ .9/ Bottle #'s: 2. Non Potable 4. Other Chain of Custody?___ yes___ no Time/Date Collected: 26 /1'- Comments:____________________ Collected By: 1//1< Ci Oa/ Agi :ode: PWS #:______ Source ID: Type Descriptor: Collected From: Bill to: Location’s/lndividual's Name Name/Company Street_________ Street________ City/St/Zip_________ L. 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 • f 1. Trihalomethane's (524) 1. Purgeable Halocarbons (624/8260) Count (hemodialysis & all others) Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260) 2. Coliform P/A (public supplies) 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) e^^roscopic @ Pesticides/PCB screen (508) 7. Methoprene (616) 7WIFI 8. PCB as Decachlorobiphenyl (5p8A) 8. Herbicides (EPA1978/8151) 8. Other:____________________ Herbicides (515) 9. Pesticides (SMI8/6630) Refrigerated?yes Chlorinated:?;yes no no § Pesticides (525) Carbamate Pesticides (531) 12. Glyphosate4547) 10. Petroleum Hydrocarbon Scan (310-13)?. 11. Glycols 12. Acid Extractables (625/8270) 13. Diquat (54^ • la 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:. . f /--------

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 CaCOa CLP 9. Chemical Oxygen Demand 28. Nitrogen, Ammonia as N 47. Calcium, Ca*^ 66. Metals/CN 10. Dissolved Oxygen 29. Nitrogen, Nitraje as N 48. Chromium, Total 67. Volatiles 11. Total Organic Carbon 30. Nitrogen, Nitritit^s N 49. Chromium, Hexavalent 68. Semi-violatiles 12.^Total Organic Halides 31. Nitrogen, TotalI *eldahl as N 50. Cobalt 69. Pesticides/PCB’s ^^olids. Percent (%) 32. Oil an Grease 51. Copper 70. Disk Deliverables ^Kolids, Settleable 33. Phenol 52. Iron TCLP iTsolids, 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; ini 38. UV254 57 Molybdenum 75. TCLP-BNA’s 58. Nickel

NYC-WTC_000071902