Chain of custody form, Westchester County Labs

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ster iv.com WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914) 593-5575 IS or 5 NYS-ELAP No. lOl^k Time/Date Set: . - '-^7 Form A-70 (rev.1/9^IF

Sample Type (circle one); - ■.

1?Potable 3. Non Potable Treated Bottle #’/r‘

2. Non Potable 4. Other Chain of Custody? _h_ yes JAni !

Time/Date Collected: O' - ___ Comments: Y- Collected By: 7. ■ i 'i .j/ v;* "VAaencv Code: PWS #:_________ __ Source ID: Type.peTOriptor: s.»- Collected From; Bill to: Location’s/lndividual’s Name 7'^ AW Name/Company ■ ■ Street . ’___________ Street ' City/St/Zip -'■- '■ ________ City/St/Zip Identification of Source 2__ 1 Phone#: - ■ i‘Fax#: ‘h.-

Collection Point ca;ch, bi? AiAL Checl^;-2_il . f Amounts V fZW <f 'iW' ■ •

BACTERIOL^ICAL ANALYSIS .^ANICPOTABIAA^^ Lab#: _______ (circle tests) ' S, (circle tests) > - 1./ Purgeable Halocarbonst'(^4/8260)' \ 1. Heterotrophic Plate , 1. Trihalomethanes (524)^;g't‘ Count (hemodialysis & all others) /'S’;. Volatile Halocarbons (524) 2.' Purgeabie Aromatics (^^82’60) 2. Coliform P/A (public supplies) , 3. VolaWAromatics (524) 3. Acrolein & Acrylonitrile 7624) 3. Coliform MPN (privwell, raw. stp) Total Trihalomethane Potential (510) 4. Phthalates (625/8270) '-;A9 4. Fecal Coliform (all samples) 5. Microextractables (504) . 5. Organochlorine Pesticides9608/8081) 5. Microscopic 6. Pesticides (507)| / 6. PCB’s (Arochlors) (608^1) :* A 6. Macroscopic ' 7. Pesticides/PCB screen (508) 7. Methoprene (616) 7. API 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPAI 978/8157) r 8. Other: ________________ 9. Herbicides (515) ' 9. Pesticides (SMI8/6630)^^. f id- Pesticides (525) ■ '10. Petroleum Hydrocarbon Scan (310-13) Refrigerated? yes no ii. Carbamate Pesticides (531) ' ■ TII. Glycols Chlorinated:? yes,___ no 12. Glyphosate (547) .12. Acid Extractables (625/8270) 13, Diquat (549) ‘ „ 13^ase Neutral Extractables (625/8270), Free Chlorine Res:. _______ rng/L 14, Chlorination Disinfection Byproducts (551) d^C/MS Semivolatile Unknown Scan, ' 15, Haloacetic Acids (552) . 15. Purgeable Halocarbons (DEF) / Total Chlorine Res: ______ _ mg/L 16. Pesticides (SMI 8/6630) J 16.iPurgeable Aromatics (DEF) / pH 17. Petroleum/Hydrocarbon Scan (310-13) '■'‘.17.'Pesticides/PCB's (DEF) 18. Qther:; ;Tl8.Other:.

INORGANIC ANALYSIS REQUESTED - Lab#: (circle tests) 1. Color 20. Acidity .■’’GdYMunji^um 59, Potassium • 2. Turbidity 21. Alkalinity, as CaCOa 46. Antimony 60. Selenium 3. pH 22. Bromide 41. Arsenic 61. Silver ; 4. Conductivity 23. Bromate/Chlorate/Chlorite 42. Barium 62. Sodium . 5. Corrosivity (temp:. 6. BOD (5 day) • 7. Soluble BOD (5 day) ®C) 24. Chloride 25. Cyanide 26. Fluoride 43. Beryllium 44. Boron 45. Cadmium 63. Thallium 64. Vanadium / 65. Zinc j Zv 8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOa 46. Calcium, as CaCOs GL£ 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 34. Phosphorus Total as P 53. Lead I£LP 15. Solids, Suspended 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 57 Motybdenum 74. TCLP-Volatiles 19. Other:_________________ 38. UV254 75.TCLP-BNA's 58. Nickel

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