Chain of custody record, Westchester County Department of Labs

NYC 9/11 Public Portal Document I

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM

Time/Date Set: ster »vcom WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914)593-5575 / - - B NYS-ELAP No. 10108 Form A-70 (rev. 1/96)

Sample Type (circle one): 1. Potab^ 3. Non Potable Treated Bottle jTs: 2. Non Potable 4. Other Chain of Custody?___ yes___ no Time/Date Collected: ■' ? / ■-' Comments:__________________ Collected By: ' Agency Code: PWS #:______ Source ID: Type Descriptor: Collected From:" Bill to: Location’s/lndividual’s Name Name/Company Street_____________________ Street________ City/St/Zip■ City/St/Zip Identification of Source Phone#: » Fax#: Collection Point / 4 / J O CA,CH. Bi? I Check#: Amounts.

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) 2. 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. F^cal Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8081) 5. I^^scopic 6. Pesticides (507) 6. PCB’s (Arochlors) (608/8081) 6. I^Broscopic 7. Pesticides/PCB screen (508) 7. Methoprene (616) 7. API 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151) 8. Other:_____________________ 9. Herbicides (515) 9. Pesticides (SMI8/6630) 10 Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13) Refrigerated?yes no 11. Carbamate Pesticides (531) 11. Glycols 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) 14. GC/MS Semivolatile Unknown Scan Total Chlorine Res: mg/L 15. Haloacetic Acids (552) 15. Purgeable Halocarbons (DEF) 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. 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, Nitrate as N 48. Chromium, Total 67. Volatiles 11. Total Organic Carbon 30. Nitrogen, Nitrite as N 49. Chromium, Hexavalent 68. Semi-violatiles 1^Mal Organic Halides 31. Nitrogen, Total Kjeldahl as N 50. Cobalt 69. Pesticides/PCB’s 13^Plids, Percent (%) 32. Oil an Grease 51.Copper 70. Disk Deliverables 14. Solids, Settleable 33. Phenol 52. Iron 34. Phosphorus Total as P 53.Lead • tclp 15. Solids, Suspended 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:_________________ 38. UV254 57 Molybdenum 75. TCLP-BNA's 58. Nickel NYC-WTC_000072085