Chain of custody record, Westchester County Department of 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 NYS-ELAP No. 10108 ^Wne/Date Set: Form A-70 (rev. 1/96) Sample Type (circle one): 3. Non-Potable Treated Bottle f^s:~ , * ( Potable 7 2. Non-Potable 4. Other_____________ Chain of Custody? .yes ____ no Time/Date Collected:, Comments: Collected Bv: / 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 -3. . I CA, CH, Bl?. Check#:, . Amounts.

BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES Lab#:______________________ Lab #: ' _____ (circle tests) (cirr.le tests) c- ^7 ' / 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 (606/8060) ; 4, Fecal Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8080) 5. Microscopic ' 6 Pesticides (507) 6. PCB's (Arochlors) (608/8080) 6. Macroscopic Pesticides/PCB screen (508) 7. Herbicides (SM-18/6640; 8151) ||AP: 8. PCB as Decachlorobiphenyl (508A) , 8. Other Pesticides (SM-18/6630) ™Other:___________________ 9. Herbicides (515) (■ 9. Petroleum Hydrocarbon Scan (310-13) Pesticides (525) r 10. Glycols in’Water } Refrigerated?' yes no 11. Carbamate Pesticides (531) ' - 11. Acid Extractables (625/8270) 12. Glyphosate (547) J.2^Base Neutral Extractables (625/8270) ' '‘Chlorinated?: .yes. .no 13. Diquat (549) ^3}gC/MS Unknown Scan > ,14. Chlorination Disinfection Byproducts (551) 1'4^ Purgeable Halocarbons (DEF) , Free'Chiorine Res:______ L^mg/L-. *15. Haloacetic Acids (552) 15. Purgeable Aromatics (DEF) * 'Jt *• ' t 16. Other Pesticides (SM-18/6630) 7, 16. Pesticides (DEF) (Total Chlorine Res:-- • rnq/L 17.’. Petroleum/Hydrocarbon Scan (310-|3)' 17. PCB's (Arochlors) (DEF)

•pH _ — INORGANIC ANALYSES REQUESTED - Lab#:. ________ (circle tests) ‘ Q.3 ■S’? 1. Color 20, Acidity 39. Aluminurti 59. Potassium ; 2. Turbidity ' 21. Alkalinity, as CaCOa 40. Antimony; 60. Selenium \ 3. pH; - 22; Bromide 41. Arsenic-: 61. Silver i 4. Conductivity 23, Bromafe/Chlorate/Chlorife 42. Barium^'i; 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 CaCOa 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-volatiles 12. Total Organic Halides 31, Nitrogen, Total Kjeldahl as N 50. Cobalt 69. Pesticides/PCB’s 1^. Solids. Percent (%) 32, Oil and Grease 51. Copper 70. Disk Deliverables Solids, Settleable 33. Phenol 52. Iron TfiLE 15. Solids, 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:_________________ 38. IIV254 57. Molybdenum 75. TCLP-BNA’s 58. Nickel

NYC-WTC_000072314