Chain of custody form, Westchester County Labs

NYC 9/11 Public Portal Document

«UL ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH 1^ 2 Dana Road, ValhaDa, New York 10595 (914)593-5575 NYS-ELAP No. 10108 ime/Date Set: : Form A-70 (rev. 1/96) Sample Type {circle one): ( iJPotable ' ; 3. Non-Potable Treated ■■

2. Non-Potable" •. 4. Other___________ . Chain of Custody? yes ' no Time/Date Collated: €77^0 .... Comments:j Collected Ry: Tj/'C* /I 'Agency Code; PWSs: Source ID:^ Type Descriptor;, Collected From: ■, ■ 1 u ... .Location's/lndividual’s Name______ _/M-___e_2c./_Z_j^£^''''cName/Compi I any. Street' / Street City/SVZip Identification of Source,, Phone#; Fax #: Collection Point'' ' __ ___________ rCA7cH~Bi7 Check#: Amounts

BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES^ ORGANIC NONPOTABLE/SOLID ANALYSES Lab .............. ■......... , ....... , ° y icircle lesls) I S 1 } (circle tests) 1 .-.Heterotrophic Plate ■ 1. 1 rihalomethahes'(524) - 1. Purgeable Halocarbons (624/8260) Count (hemodialysis & all others) ■21 Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260) 2. Coliform P/A {pubhc supplies) 3.) Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624) 3, Coliform MPN (priv well, raw. stp) I J: .■,.■■■■■■ 4. Fecal Coliform (all samples) ^^Microscopic 6.^ Pesticides (507) 6. PCB’s (Arochlors) (608/8080) WMacfoscopic fS~=5„ "ap: Other;^./___ ___1___________

Refrigerated?..... c.yes; ■ no. i*S=SL,„. sS ■ • ■ ' 7?'.. ' ' 12, Glyphosate (547) ■

Chlorinated^:yes.. „_no IT DY .rat (542*

Free Chlorine Res:....■ mg/L 1= r. ■.../C At.r.:.-i r (CFF) 1. r... c.:(nr- Ch^jcine Res? mg/L ■ i CH 17. PCB’s (Arochlors) (DEF)

IK ■ ,

INORGANIC ANALYSES REQUESTED ■■ Lab#;..... (circle it;?*?) /- 1. Color 20. Acidity 39. Aluminum 59; Potassium 2. Turbidity 21.AikaHmty.asCaCO3 < 40^ntimony j 60. Selenium 3. pH 22. Bromide 61. Silver 4. Conductivity 23. Bromate/Chtorate/Chiorile '62^ Sodium alOlijjlllilllll 5. Corrosivity (temp:____ .“C) 24. Chloride : 63.yrhaliium , 6. BOD (5 day) 25. Cyanide \64/Vanadiurn' - 7. Soluble BOD (5 day) ' 26. Fluoride ■5. Cadmium 65. Zinc ) ilimOlB 8. Carbonaceous BOD (5 day)) 27. Hardness, Total as CaCO3 46.^Calcium, as CaCOa CLP -1 9,/Chemical Oxygon Demand "" .............. * Jiaicium, Ca*’ 66. Metais/CN

I 10. D .oived Oxygen 11 Organic Carbon 29. Nitrogen, Nitrate as N 30. Nitrogen, Nitrite as N 1 •Chromium. ■9; Chromium, Total Hexavalent 67, Volatiles; 68. Semi-volatiles U Organic Halides ds. Percent (%) ds, Settieable 31. Nitrogen, Total Kjeldahl as 32. Oil and Grease 33. Phenol ■ &e,

I.CLP^ ,.c iH -16. Soni 17. Soln al

i actants^ 154

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