Chain of custody form, Westchester County Labs

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM IP tiester Kov.com WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914) 593-5575 NYS-ELAP No. 10108 'Date Set: ■■ - Form A-70 (rev. 1/96)

Sample Type (circle one); ?! // i .'Potable 3. Non Potable Treated Bottlers: /- 2! Non Potable 4. Other______________________________ Chain of Custody?___ yes no Time/Date Collected:______ I Comments: Collected By: ? /i, ^ AfAaencv Code: PWS #:______ Source ID: .Type Descriptor: Collected From: Bill to: ' I?-" Location’s/lndividual’s Name /■ / f C I '' Name/Company Street______________________________ __________________ Street_______ r City/St/Zip -. _________________________________ City/St/Zip Identification of Source ~ • Phone#: Fax#: . •• •. A Collection Point CA.CH, Bl? Check#: '-Amounts

BACTERIOLOGICAL ANALYiSiS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLIDANAlWisI Lab#: (circle tests) ‘jXe tests) . n ••v- 1. Purgeable Halocarbons’; (624/826b) *|O 1. Heterotrophic Plate 1. Trihalomethanes (524) t Count (hemodialysi^ & all others) /"SAVolatile Halocarbons (524) 2. Purgeable Aromatics (624^260) 2. Coliform P/A (public supplies) Ls-A/olatile Aromatics (524) 3. Acrolein & Acrylonitrile (624) t 3. Coliform MPN (priv well, raw, stp) 4. Total Trihalomethane Potential (510) 4. Phthalates (625/8270) 4. Fecal Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8081)/X I 5. Microscopic e;' Pesticides (507) 6. PCB’s (Arochlors) (608/8081) ' > j 6.J|^roscopic Pesticides/PCB screen (508) 7. Methoprene (616) ' '^8? PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPAI 978/8151) 8. Other:. .9. Herbicides (515) 9. Pesticides (SMI8/6630) 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) (J4j)3C/MS Semivolatile Unknown Scan Total Chlorine Res: mg/L 15. Haloacetic Acids (552) 15. 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#: (circle tests) 1. Color 20. /Scidity 39. Aluminum 59. Potassium I 2. Turbidity 21. Alkalinity, as CaCOs 40. Antimony 60. Selenium i 3. pH 4. Conductivity 5. Corrosivity (temp:. .®C) 22. Bromide 23. Bromate/Chlorate/Chlorite 24. Chloride 41. Arsenic 42. Barium 43. Beryllium 61. Silver 62. Sodium 63. Thallium tM 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 CaCOs 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 12.'Total Organic Halides 31. Nitrogen, Total Kjeldahl as N 50. Cobalt 69. Pesticides/PCB’s 1 ^Solids, Percent (%) 32. Oil an Grease 51. Copper 70. Disk Deliverables ^kolids. Settleable 33. Phenol 52. Iron TCLP WRolids, 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. UV254 57 Molybdenum 75. TCLP-BNA’s 58. Nickel

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