Chain of custody form, Westchester County Labs

NYC 9/11 Public Portal Document

s ...etor ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH Be ‘ 2 Dana Road. Valhalla, New York 10595 (914) 593-5575 NYS-ELAP No'. IO1A Time/Date Set: /p Form A-70 (rev.1/90|F

Sample Type (circle one): / ^Potable -’-S. Non Potable Treated Bottle #*8: 2. Non Potable 4. Other , ; Chain of Custody?___ yes no 7- Time/Date Collected: Comihents:__________________ Collected By: Agency Code: PWS#;_______ Source ID: Type Descriptor: Collected From: * BUI to: T»*;' Location's/lndividual’s Name Name/Company street____________ Street City/St/Zip •' • A- *'* ■ . City/St/Zip;__ 4;^ Identification of Sourci ,fjphoA«SiL. iM Fax#: Collection Point L^^Check#:^ AmountS v^'- aV-iwx j : %«>'..•

BACTERIOLOGICAL ANALYSIS/ v, Lab#:_______________ (circle tests) 1. Heterotrophic Plate ' V-3T- 1. Trihalomethanes (524) 7^7 iC ^’PurgeaWe Halocarbons (624/8260); . ’ Count (hemodialysis & all othere), Volatile Haiocarboris^'(524) ■ <22. Purgeable>romatics (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 Trihaiomethane Potential (510) 4. Phthalat^ (625/8270) . 4. Fecal Coliform (all samples) 5. Microextractables’(5O4j. 5. Organochlorine Pesticides (608/8081) 5.-Microscopic Pesticides (507)^-^^ /I" 6. PCB’s (Arochlors) (608/8081) ' -® 6. Macroscopic Pesticides/PGB ^reen'(508) .; 7. Methoprene (616) 7. APh. 8. PCB as Decachldrobiphenyl (508A) .f 2? 8. Herbicides (EPAI 978/8151) 8. Other:_____________________ ^Herbicides; (515) 9. Pesticides (SMI 8/6630) ’(^-Pesticides ,(525) 10. Petroleum Hydrocarbon Scan (310-13) "’ Refrigerated? yes___ no It Carbamate'ljesticides (531) 11. Glycols Chlorinated:? yes no 12. Glyphosate X547) 12. Acid Extractables (625/8270) . • ^1' 13. Diquat (549} 13-_pase Neutral Extractables (625/8270) Free Chlorine Res:. mg/L 14. Chlorination Disinfection Byproducts (551) ^^GC/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:__________ £12_______ 18. Other:r:

INORGANIC ANALYSIS REQUESTED - Lab#; > (circle tests) ' 03 i : 1. Color , . 20. Acidity - "SO^AIuna^um 59. Potassium 2. Turbidity 21. Alkalinity, as CaCOs 22. Bromide 40. Antirriony 41. Arsenic 60. Selenium 61. Silver t "K' 3. pH 4. Conductivity 23. Bromate/Chlorate/Chlorite 42. Barium 62. Sodium 5. Corrosivity (terhp:. .’C) 24. Chloride 43. Beryllium 63. Thallium 6. BOD (5 day) 25. Cyanide 44. Boron Vanadium 7. Soluble BOD (5 day) 26. Fluoride. 45. Cadmium Zinc 1 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 13. Solids, Percent (%) 32. Oil an Grease 51. Copper 70. Disk Deliverables 14. Solids, Settleable 33. Phenol . 52. Iron TC-LP 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. UV254 57 Molybdenum 75.TCLP-BNA’s 58. Nickel

NYC-WtC_000072524'