Chain of custody form, Westchester County Labs

NYC 9/11 Public Portal Document

'i: ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM

Time/Date Set; ster v.com WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914) 593-5575 NYS-ELAP No. 1 II Form A-70 (rev.1 ___ o

Sample Type (circle one); 7^ 1 .''Potable 3. Non Potable Treated Bowers; yf i'7 j. a ■ 2. Non Potable 4. Other Chain of Custody?___ yes no Time/Date Collected: t?/ Comments:_______________ , Collected By: farqaaai Agency Code: PWS#:_____ Source ID: .Type Descriptor _ Collected From: : Bill to: Location’s/lndividual’s Name , Name/Company ■• ..

Street_______________________ Street _____ City/St/Zip___________________ __________ ___. . - Citv/St/Zip Y.Phorie^.:j|^^^ Identification of Source _________ _________ LliFax#: • ...? ■

Collection Point _ _Check#;'7---------- AnrountS "

BACTERIOLOGICAL ANALYSIS Lab#:_________________ (circle tests) 1. Heterotrophic Plate Count (hemodialysis & all others) /'Zyolatile Halocarbons’^ (524) W.;: , - " . •• ' -'Xs-y 1. Purgeable Halocarbons ^(624/8260) ■ . Z Purgeable'Aromatics;(62478260) 7 2. Coliform P/A (public supplies) v3./Volatile Aromatics' (524)"7, ; 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)j 5. Organochlorine Pesticides (608/8081) 5. Microscopic 6. Pesticides (507) .^5'0-'- ' : ; 6. PCB’s (Arochlors) (608/8081) 6. Macroscopic ‘/ /■^.'Pesticides/PCB screen (508) ; • ' 7. Methoprene (616) 7. API “8. PCB as Decachlorobiphenyl (508A) ' 8. Herbicides (EPAI 978/8151) ?■ 8. Other:_______ ;_____________ ^9.. Herbicides (515) 9. Pesticides (SMI 8/6630) Refrigerated?___ yes___ no •,^10.' Pesticides (525) •10. Petroleum Hydrocarbon Scan (310-13) ’ Tl. Carbamate Pesticides (531) 11. Glycols , i 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) /^4. 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:j>. •<49 5 INORGANIC ANALYSIS REQUESTED - Lab#; f (circle tests) 1. Color 20. Acidity 59. Potassium 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. Sodiurn 5. Corrosivity (temp:, .’C) 24. Chloride 43. Beryllium 63. Thalliu'm 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 13. Solids, Percent (%) 32. Oil an Grease 51. Copper 70. Disk Deliverables 14. Solids, Settleable 33. Phenol 52. Iron TQLR 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

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