Chain of custody form, Westchester County Labs

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM tester WESTCHESTER COUNTY LABORATORIES AND RESEARCH nov.com 2 Dana Road, Valhalla, Now York 10595 (914) 593-5575 NYS-ELAP No. 10108 /Date Set: . Form A-70 (rev. 1/96)

Sample Type (circle one); ^,^otable 3. Non Potable Treated Bottle 52- "M3 2. Non Potable 4. Other Chain of Custody?___ yes no Time/Date Collected;. f :> ■ Comments:__________________ Collected By: / < AO Agency Code: PWS #:______ Source ID: Type Descriptor; Collected From:i Bill to: Location’s/lndividuai’s Name. Name/Company Street_______________________________ Street________ City/St/Zip_______________ :____________ City/St/Zip Identification of Source Phone#; Fax#; Collection Point CA,CH. Bi? 2 h Checloft _ Amounts.

BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS J ORGANIC MONPOTABLE/SOLID ANALYSIS' Lab#:___________ ___________ Lab#;__ ' ) f • (circle tests) (circle tests) V' 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) 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) ^^^roscopic 7. Methoprene (616) Pesticides/PCB screen (508) a PCS as. Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151) 8. Other:____________________ a Herbicides (515) 9. Pesticides- (SM.18/6630) @ Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13),, Refrigerated?yes___ no 11. Glycols O 11. Carbamate Pesticides (531) Chlorinated;? yes no 12. Glyphosate (547) 12. Acid Extractables (625/8270) - 13. Diquat (549) 13,Base Neutral Extractables (625/8270) ’ Free Chlorine Res:. mg/L 14. Chlorination Disinfection Byproducts (551) ^^)gC/MS Semivolatile Unknown Scan 15. Haloacetic Acids (552) 15. Purgeable Halocarbons (DEF) Total Chlorine Res: 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:_________________ _______

INORGANIC ANALYSIS REQUESTED - Lab#; (circle tests) 1. Color 20. /'cidity 39. Aluminum 59. Potassium 2. Turbidity 21. Alkalinity, as CaCOa 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'-^ 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 Il. 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 J^^olids, Percent (%) 32. Oil an Grease 51.Copper 70. Disk Deliverables ^Bsolids, Settleable 33. Phenol 52. Iron 53.Lead ICL£ lT Solids, Suspended 34. Phosphorus Total as P 54 Magnesium 71.TCLP-Metals 16. Solids, Total 35. Phosphorus, Ortho as P 72.TCLP-Pesticides 17. Solids, Total Dissolved 36. Sulfates 55 Manganese 73. TCLP-Herbicides 18. Solids, Total Volatile 37. Surfactants 56. Mercury i 74. TCLP-Volatiles I 19. Other:_________________ 38. UV254 57 Molybdenum 75.TCLP-BNA's 58. Nickel

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