Chain of custody form, Westchester County Labs

NYC 9/11 Public Portal Document

JL ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914) 593-5575 NYS-ELAP No. 10108 Wwme/Date Set:_________ c » Form A-70 (rev. 1/96) 1 s. \ Sample Type (circle one): •»»,, Sa . . 1. Potable 3. Non-Potable Treated Bottle #'^ a '-j a A- L '1

2. Non-Potable 4. Other Chain of Custody? .yes .no Time/Date Collected:t C. - - C5 . Comments; Collected By: V-f <tt * .Agency Code: PWS #;_________ .Source ID; J Type Descriptor;, Collected From: Bill to; .'■5 Location’s/ln dividual’s Name. Name/Company Street_________ ' Street__________ Citv/SVZiD ■■ ■ ■_______ City/St/Zip Identification of Soprce^ Phone#:, Fax#:, J-SX Collection Points . I CA, CH Bl? ,,;jCheck#L J>A^

bacterioloqkXal analyses ORGANIC POTABLE ANALYSES Lab#:____21£i_i_;_______ . Lab #; / (circle tests) ‘’1. ) ' ’ (drr.le lesls) 1. Heterotrophic Plate Trihalomethanes (524)' 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)J 4. Fecal Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/i3080)X 5. Microscopic 6. Pesticides (507) .6. PCB’s (Arochlors) (608/8080) t'-S. 6. Macroscopic Pesticides/PCB screen (508) ' • 7. Herbicides (SM-18/6640*8151)’ PCB as Decachlorobiphenyl (508A) 8. Other Pesticides (SM-i 8/6630) ) Br Other;_________ j_________ 9 Herbicides (515) 9. Petroleum Hydrocarbon'Scan (310-13) , Pesticides (525) 10. Glycols in Water ' \ Refrigerated? .yes. no 11. Carbamate Pesticides (531) 11. Acid Extractables (625/8270) 12. Glyphosate (547) 1^ Base Neutral Extractat)ies(625/8270‘) — Chlorinated?: .yes. .no 13. Diquat (549) OgC/MS Unknown Scan 14. Chlorination Disinfection Byproducts (551) Purgeable Halocarbons (DEF) Free Chlorine Res; mg/L 15. Haloacetic Acids (552) 15. Purgeable Aromatics (DEF) . 16. Other Pesticides (SM-18/6630) 16. Pesticides (DEF) Total Chlorine Res: mg/L 17. Petroleum/Hydrocarbon Scan (310-13) 17. PCB’s (Arochlors) (DEF)

pH

INORGANIC ANALYSES REQUESTED - Lab#: (circle tests) CO 1. Color 20. Acidity 39. Alu'rtiinum 59. Potassium 2. Turbidity 21. Alkalinity, as CaCOa 40. Antimony 60. Selenium 1 3. pH 22, Bromide 41. Arsenic 61. Silver .1 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 J 8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOa 46. Calcium, as CaCOa 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 I. Solids, Percent (%) 32. Oil and Grease 51. Copper 70. Disk Deliverables . Solids. Settleable 33. Phenol 52. Iron TCLP 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. S(|lfates 55. Manganese 73. TCLP-Herbicides 18. Solids. Total Volatile 37. Surfactants 56. Mercury 74. TCLP-Volatiles 19. Other:_______________ 38. L1V254 57. Molybdenum 75. TCLP-BNA’s 58. Nickel

NYC-WTC_000072447