Chain of custody form, Westchester County Labs

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM - jr iv.com WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dan6' Road, Valhalla. New York 10595 (914) 593-5575

Time/Date Set: c *• 3 . NYS-ELAP No. 1 ^F^ A-70 (rev.1

Sample Type (circle one): Quotable 3. Non Potable Treated 2. Non Potable 4. Other Chain of Custody? yes no Time/Date Collected: 7/ C / Comments: Collected By: Agency Code: Source ID: Type Descriptor: Collected From: Location’s/lndividual's Name /7X Narn^Company 1

Street___________________ 8i»____ : City/St/Zip ■ ': .,1 r “W-— ' -Fax#: Identification of Source Collection Point BX s "Wz— Checkilf;;^^ Amounts ■ S' ■

BACTERIOLOGICAL ANALYSIS ORGANid F®BL<®LTSIS^^^ organ,CNONPOTABLBSOLIDANALYS,?- Lab#;____________ Lab#: (circle tests) ■ S’- 1. Heterotrophic Plate 1. Trihalomethanes;X524) WMy - T. Purgeable Halocarbons (624/8260) ntf Count (hemodialysis & all others) /2. 'Yolatile Halocarbcins '(524) 2. Purgeable Aromatics (624/8260) 2. Coliform P/A (public supplies) ka^Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624) v 3. Coliform MPN (privwell, raw,stp) 4. Total Trihalomethane Potential T510) 4. Phthalates (625/8270) ' ', 4. Fecal.Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8081) - 5, Microscopic a Pesticides (507) Y-J;,. j . 6. PCB’s (Arochlors) (608/8081) A 6. Macroscopic jf^'Pesticides/PCB screen^(508) f 7. Methoprene (616) ' ” 7. API 8’ PCB as Decachlorobiphenyl (508A)*^,/ 8. Herbicides (EPAI 978/8151) 8. Other: ____________________ Herbicides (515) Y; 9. Pesticides (SMI8/6630) / do?;Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13) / Refrigerated?yes no T l.' Carbamate Pesticides (531) 11. Glycols A Chlorinated:?yes no 12. Glyphosate (547) ■ 12. Acid Extractables (625/8270) 13. Diquat (549) n. Base Neutral Extractables (625/8270) Free Chlorine Res: mg/L 14. Chlorination Disinfection Byproducts (551) (^4^C/MS Semivolatile Unknown Scan Total Chlorine Res: mg/L 15. Haloacetic Acids (552) 15. Purgeable Halocarbons (DEF) 16. Pesticides (SMI 8/6630) 16. Purgeable Aromatics (DEF) . pH 17. Petroleum/Hydrbcarbon Scan (310-13) 17. Pesticides/PCB’s (DEF) , 18. Other:__________________________ 18. Other:f

INORGANIC ANALYSIS REQUESTED - Lab#: I 4 (circle tests) -i- f 1. Color 20. A:idity . 39k Aluminum f ’ 59. Potassium’ 2. Turbidity 21. Alkalinity, as CaCOa - 40. Antimony 60. Selenium । 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 ; 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 CaCOa ■ '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. Mitrdgen, 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 '■ tCLP 15. Solids, Suspended 34. Phosphorus Total as P 53.Lead 71 TCLP-Metals 16. Solids, Total 35. Phosphorus. Ortho as P 54 Magnesium 55 Manganese 72.TCLP-Pesticides 17. Solids, Total Dissolved 36. Sulfates 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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