Chain of custody form, Westchester County Labs

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ^VOOtn WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914) 593-5575 — NYS-ELAP No. 10108 ^^e/Date Set: C-T 7 7 r ^^^^A-70(rev.1/96) ------ U— Sample Type (circle one): Bottle #’^ a I 1. Hotable 3. Non Potable Treated '2; Non Potable 4. Other________________________ Chain of Custody? yes __ no Time/Date Collected: /f /7 O 3> Comments: Collected By: S ■ /f f. <::V 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 ; 0^^ Phoned _______ Fax#: Collection Point 7 Check#: - , C’tAfTOuh^^O^VY: CA.CH, Bl?

BACTERIOLOGICAL’ANAl^SIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/sbuDANALYSrS Lab#:_____ 2__S£___ Lab#:_________ ■ ■ ' '-WMS'-W (circle teste) . •- (circle teste) 1, Heterotrophic Plate 1. Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260),'. J Count (hemodialysis & all others) /'2?i Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260) ‘ 2. Coliform P/A (public supplies) '^3/ Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624) r 3. Coliform MPN (priv well, raw, stp) 4. Total Trihalomethane Potential (510) 4. Phthalates (625/8270) fS;. 4. Fecal Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8081) 5. Microscopic Pesticides (507) 6. PCB’s (Arochlors) (608/8081) ^7.' croscopic Pesticides/PCB screen (508) 7. Methoprene (616) I 8? PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPAI 978/8151) .. 8. Other:________ ____________ ^Herbicides (515) 9. Pesticides (SM18/6630) Refrigerated?yes no QQ . Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13) Vl. Carbamate Pesticides (531) 11. Glycols Chlorinated:? yes no 12. Glyphosate (547) 12. Acid Extractables (625/8270) , 13. Diquat (549) 131. Base Neutral Extractables (625/8270) Free Chlorine Res:. mg/L 14. Chlorination Disinfection Byproducts (551) p^GC/MS Semivolatile Unknown Scan Total Chlorine Res: mg/L 15. Haloacetic Acids (552) T5. Purgeable Halocarbons (DEF) 16. Pesticides (SMI8/6630) 16. Purgeable Aromatics (DEF) pH 17. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB’s (DEF) 18. Other:__________________________ 18. Other:_______________ .______ __

INORGANIC ANALYSIS REQUESTED - Lab#: i (circle tests) 39: Alunjinumii V ■ 59. Potassiuni^ 1. Color 20. Acidity . 2. Turbidity 21. Alkalinity, as CaCOs 40. Antimony 60. Selenium ! y 3. pH 22. Bromide 41. Arsenic 61. Silver | 4. Conductivity 23. Bromate/Chlorate/Chlorite 42. Barium 62. Sodium i 5. Corrosivity (temp:, .®C) 24. Chloride 43. Beryllium 63. Thallium j 6. BOD (5 day) • 25. Cyanide 44. Boron 64. Vanadium 1 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 CLP T 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 12.''Total Organic Halides 31. Nitrogen, Total Kjeldahl as N 50. Cobalt 69. Pesticides/PCB’s ^Solids, Percent (%) 32. Oil an Grease 51. Copper 70. Disk Deliverables ^^Eolids, Settleable 33. Phenol 52. Iron Solids, Suspended 34. Phosphorus Total as P 53.Lead I£kE 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 -3^ NYC-WTC_000072448