Chain of custody form, Westchester County Labs

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM

Time/Date Set: 'Ster )v.com WESTCHESTER COUNTY^BORATORIES AND RESEARCH 2 Dana Road, \^lhalla, New York 10595 (914) 593-5575 I

J 7 / r I® NYS-ELAP No. 101(^^ Form A-70 (rev.1/96^F

Sample Type (circle one): 4"/ >■ 9 'i. SC' ■* 'y? - - '"7 7 c Bottle' W':; f'Potable 3. Non Potable Treated 2. Non Potable 4. Other Chain of Custody?yes___ no Time/Date Collected: -1 g - ' I Comments: Collected By; i^VAgency Code; L "'^WS#: Source ID: Type Descriptor: Collected From: Bill ¥0: Location’s/lndividual’s Name Name/Company ' Street Street____________________ 5 City/St/Zip________________ City/SVZip: - Identification of Source - Ph6ri^'|^iJL2L_ ■■■ Fax#: - Collection Point Sb '*’1 -iWi * - - /I CA.CH: Checl^f >■ '^Amounts - • •

BACTERIOLOGICAL ANALYSIS Lab#:.______________________ (circle tests) (circle tests) 1. Heterotrophic Plate J. Tri halometh an es(524)'''-‘' 1. Purgeable Halocarbons* (624/8260) rY Count (hemodialysis & all others) Volatile Halocarbons (524) 2.;■ Purgeable Aromatics' (624/8260) cr; 2. Coliform P/A (public supplies) \3,' Volatile Aromatics (524) 3. Acrolein & Acrylonitrile <&4) 3. Coliform MPN (priy,well, raw, stp) 4. Total Trihalomethane Potential '‘(510) 4. Phthalates (625/53270)• . — 4. Fecal Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides''(608/8081) 5. Microscopic 6, Pesticides (507) ' 6. PCB’s (Arochlors) (608/8081) . 6. Macroscopic ,7.’ , Pesticides/PCB screen (508) 7. Methoprene (616) W 7. API 8. PCB as D^chlorobiphenyl (508A) 8, Herbicides (EPAI 978/81'51) 8. Other:____________________ 9. Herbicides (§15) 9. Pesticides (SM18/6630)>’ (1^ Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13) Refrigerated? yes no tl. Carbamate Pesticides (531) 11. Glycols Chlorinat^:? yes___ no 12. Glyphosate (547) 12. Acid Extractables (625/8270) 13. Di^L^t (549) 13, Base Neutral Extractables (625/8270) Free Chlorine Res:. mg/L 14. Chlorination Disinfection Byproducts (551) (14) GC/MS Semivolatile Unknown Scan mg/L 15. Haloacetic Acids (552) 15. Purgeable Halocarbons (DEF) Total Chlorine Res: 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. /Acidity 39. Alum^um gg Potassium 2. Turbidity 21. Alkalinity, as CaCOs 40. Antimony f 60. Selenium t-

3. pH 22. Bromide 41. Arsenic 61. Silver 4. Conductivity 23. Bromate/Chlorate/Chlorite 42. Barium 62. Sodium 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. 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 ICLP 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_000072527