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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_000072019–000072026

Folder label: “26473

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Scanned page image, NYC-WTC_000072021
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NYC 9/11 Public Portal Document Westchester gov.com •ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914) 593-5575 ne/Date Set: Sample Type (circle one): 1.Potable 3. Non Potable Treated 2. Non Potable 4. Other Time/Date Collected: 0hoa Collected By: Ne nimьr Collected From: Location's/Individual's Name Street City/St/Zip Identification of Source Collection Point EaT CCE N/as/or Agency Code: _ NYCDF PluensiC PASCH Le: Drvve Lholla 10595 TrC-C/06 2168 Bottle #'s: Chain of Custody? Comments: PWS#:- Bill to: Name/Company Street City/St/zip Phone#t: yes suua no Source ID:_ CA,CH, BI? BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS Lab#: (circle tests) 1. Heterotrophic Plate Count (hemodialysis & all others) 2. Coliform P/A (public supplies) 3. Coliform MPN (priv well, raw, stp) 4. Fecal Coliform (all samples) Microscopic iacroscopic API 8. Other: Refrigerated? Chlorinated:? yes _ no Free Chlorine Res: Total Chlorine Res: _ yes no mg/L _mg/L рH Lab#: (circle tests) 1. Trihalomethanes (524) 2. Volatile Halocarbons (524) Volatile Aromatics (524) 4. Total Trihalomethane Potential (510) 5. Microextractables (504) Pesticides (507) ДPOredODOR aтe soo 8. PCB as Decachlorobiphenyl (508A) 9, Herbicides (515) 1Q) Pesticides (525) 11. Carbamate Pesticides (531) 12. Glyphosate (547) 13. Diquat (549) 14. Chlorination Disinfection Byproducts (551) 15. Haloacetic Acids (552) 16. Pesticides (SM18/6630) 17. Petroleum/Hydrocarbon Scan (310-13) 18. Other: INORGANIC ANALYSIS REQUESTED - Lab#: (circle tests) 1. Color 2. Turbidity 3. pH 4. Conductivity 5. Corrosivity (temp: °C) 6. BOD (5 day) 7. Soluble BOD (5 day) 8. Carbonaceous BOD (5 day) 9. Chemical Oxygen Demand 10. Dissolved Oxygen 11. Total Organic Carbon 12/ Total Organic Halides Solids, Percent (%) Solids, Settleable . Solids, Suspended 16. Solids, Total 17. Solids, Total Dissolved 18. Solids, Total Volatile 19. Other: 20. Acidity 21. Alkalinity, as CaGO3 22. Bromide 23. Bromate/Chlorate/Chlorite 24. Chloride 25. Cyanide 26. Fluoride 27. Hardness, Total as CaCOs 28. Nitrogen, Ammonia as N 29. Nitrogen, Nitrate as N 30. Nitrogen, Nitrite as N 31. Nitrogen, Total Kjeldahl as N 32. Oil an Grease 33. Phenol 34. Phosphorus Total as P 35. Phosphorus, Ortho as P 36. Sulfates 37. Surfactants 38. UV254 21173 39. Aluminum 40. Antimony 41. Arsenic 42. Barium 43. Beryllium 44. Boron 45. Cadmium 46. Calcium, as CaCO3 47. Calcium, Ca*? 48. Chromium, Total 49. Chromium, Hexavalent (50.Oobalt 51.Copper 5a fron 53.Lead 54 Magnesium 55 Manganese 56: Mercury 57 Molybdenum 58. Nickel NYC-WTC_000072021 NYS-ELAP No. 10108 Form A-70 (rev.1/96) , OFBOI N1S7 Type Descriptor: Fax#: Check#:_ Amount$ ORGANIC NONPOTABLE/SOLID ANALYSIS 1. Purgeable Halocarbons (624/8260) 2. Purgeable Aromatics (624/8260) 3. Acrolein & Acrylonitrile (624) 4. Phthalates (625/8270) 5. Organochlorine Pesticides (608/8081) 6. PCB's (Arochlors) (608/8081) 7. Methoprene (616) 8. Herbicides (EPA1978/8151) 9. Pesticides (SM18/6630) 10. Petroleum Hydrocarbon Scan (310-13) 11. Glycols 12. Acid Extractables (625/8270) 13. Base Neutral Extractables (625/8270) 14.GC/MS Semivolatile Unknown scan 15. Purgeable Halocarbons (DEF) 16. Purgeable Aromatics (DEF) 17. Pesticides/PCB's (DEF) 18. Other: Metd 59. Potassium 60. Selenium 61. Silver 62. Sodium 63. Thallium 64. Vanadium 65. Zinc CLP 66. Metals/CN 67. Volatiles 68. Semi-violatiles 69. Pesticides/PCB's 70. Disk Deliverables TCLP 71.TCLP Metals 72, TCLP-Pesticides 73. TCLP-Herbicides 74, TCLP,Volatiles 75, TCLP-BNAS

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NYC-WTC_000072021Source: NYC Law Department, mirrored locally

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NYC-WTC_000070918 · Box DEP Box 61

Chain of custody form for samples submitted to the Westchester County Department of Labs and Research in Valhalla, NY.

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