Chain of custody form, Westchester County 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 • Date Set: c- j. . Form A-70 (rev. 1/96)

Sample .Type (circle one); 01 ol . 1 ..PQtable^ 3. Non Potable Treated Bottle #’^^ /

2. Non Potable 4. Other Chain of Custody? yes J no Time/Date Collected: ■' Comments; _ Collected Bv:''^- - " Agency Code: ■ PWS#: Source ID: .Type Descriptor Collected From: Location's/lndividual’s Name ■7Name/Company •.A Street_________________ Street City/St/Zip______________ ______________ _,;; C.ty/St/Zip Identification of Source__ L_ - ^^<Phon6)t^' >4 Fax#^ Collection Point Ch^i^-.' •' Wj^'ntiW’

BACTERIOLOGICAL ANALYSIS ORGANIC POTASLE ANALYSIS 'c ? Lab#;_______________________ ■ (circle tests) (circle tests) 1. Trihalomethanes (524)’ , - 1. Heterotrophic Plate Purgeable Halocarbons (624/8260) Count (hemodiaiysis & ail'ottiS'rs) ..'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. Fecal Coliform (all samples) 5. Microextractables (504) > --4 5. Organochlorine Pesticides (608/8081 )"^' 5. Microscopic 6. Pesticides (507) J 6. PCB’s (Arochlors) (608/8081) 6^|^roscopic ;V. Pesticides/PCB screen (5O87^ ‘; 7. Methoprene (616) 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151) ...r 8. Other:____________________ 9^ Herbicides (515) ,9. Pesticides (SMI 8/6630) Refrigerated?yes no -IQ Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13) ' '' n. Carbamate Pesticides (531) 11. Glycols Chlorinated:? yes no 12. Glyphosate (547) 12. Acid Extractables (625/8270) 13. Diquat (549) I3. Base Neutral Extractables (625/8270) ',. Free Chlorine Res:. mg/L 14. Chlorination Disinfection Byproducts (551) GC/MS Semivolatile Unknown Scan 15. Haloacetic Acids (552) ^5. 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. A:idity 39. Alumj^num 5g poiagsium 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. Vanadiurn 7. Soluble BOD (5 day) 26. Fluoride 45. Cadmium 65. Zinc 8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOs 46. Calcium, ^s CaCOa CLP 9. Chemical Oxygen Demand 28. Nitrogen, Ammonia as N 47. Calcium, Ca "^2 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 12."Total Organic Halides 31. Nitrogen, Total Kjeldahl as N 50. Cobalt 69. Pesticides/PCB’s la^olids. Percent (%) 32. Oil an Grease 51. Copper 70. Disk Deliverables ■^olids. Settleable 33. Phenol 52. Iron 1 S^olids, Suspended 53.Lead TCLP 34. Phosphorus Total as P 54 Magnesium 71 TCLP-Metals 16. Solids, Total 35. Phosphorus, Ortho as P 36. Sulfates 55 Manganese 72.TCLP-Pesticides 17. Solids, Total Dissolved 37. Surfactants 56. Mercury 73.TCLP-Herbicides 18. Solids, Total Volatile 57 Molybdenum 74. TCLP-Volatiles 19. Other;_________________ 38. UV254 75.TCLP-BNA’s 58. Nickel ."A."!”-

NYC-WTC_000072444