Chain of custody form, Westchester County Labs

NYC 9/11 Public Portal Document

Ir ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM tester WESTCHESTER COUNTY LABORATORIES AND RESEARCH vcom 2 Dana Road, Valhalla, New York 10595 (914) 593-5575 NYS-ELAP No. 10108 Time/Date Set: Form A-70 (rev. 1/96) i

" / ' Samplg. Type (circle one): / 1-PQtab[e^; ' 3. Non Potable Treated Bottle #’s:____________________ 2. Non Potable 4. Other Chain of Custody?___ yes no Time/Date Collected: // Comments: ____________ Collected By: Agency Code: PWS #:______ : Source ID: Type Descriptor: A.' I Collected Prom: Bill to: Location's/lndividual’s Name. Name/Company Street__________________ Street’________ City/St/Zip _ ____________ _ City/St/Zip Identification of Source _ _ r Phone#-.' ____________ Fax#: Collection Point CA,CH;’BI? Check#: - ..sM.e. /^mounts -

B ACTERIOLOGICALANALYSIS ORGANIC POTABLE ANALYSIS' Lab#: (circle tests) ________ Lab#:________ ___________ (circle tests) - W/ 1. Purgeable Halocarbons ;(624/8260) 1. Heterotrophic Plate .1. Trihalomethanes (524) Count (hemodialysis & all others) ' 2?\ Volatile Halocarbons (524) 2. ■ Purgeable Aromatics (624/8260) 2. Coliform P/A (public supplies) 3. ,'Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624) . 3. Coliform MPN (priv well, raw, stp) Total Trihalomethane Potential (510) 4. Phthalates (625/8270) ys,.’ ' t. , 4. Fecal Colifomi (all samples) 5. Microextractables (504) 5. Organochlorine ^sticides'^ (608/8081) — 5. Microscopic 6. Macroscopic 7, API sj

8. Other:____________________ 6. Pesticides (507) Pesticides/PCB screen (508) 6. PCB as Decachlorobiphenyl (508A) 9., Herbicides (515) 'I 6. PCB’s (Arbchlojs) (608/8081) 7. Methoprehe (616) 8. Herbicides (EPAI 978/8151)'" 9. Pesticides' (SM18/6630) i;’.' ' .

jo.; Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13) -- Refrigerated?yes no rt Carbamate Pesticides (531) 11. Glycols Chlorinated:? yes___ no 12. Glyphosate (547) 12. Acid Extractables (625/8270) 13. Diquat (549) 1,3^ Base Neutral Extractables j(625/8270) Free Chlorine Res:. _______ mg/L 14. Chlorination Disinfection Byproducts (551) (M/'GC/MS Semivolatile Unknown Scan Total Chlorine Res: _______ mg/L 15. Haloacetic Acids (552) ; 15. Rufse^le Haloparbons (DEF) 16. Pesticides (SMI8/6630) 16. Purge^te-Aro'matics (DEF) Y 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^Aluminum T 1 W- IW-IS 59. Potassium 2. Turbidity' 21. Alkalinity, as CaCOa 40. AntiiTtony 60. Selenium 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. Vanadiuf*' 65. Zinc .^ 7. Soluble BOD (5 day) 26. Fluoride 45. Cadmium 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*^ P®lietals/CN 10. Dissolved Oxygen 29. Nitrogen, Nitrate as N 48. Chromium, Total °. Volatiles 11. Total Organic Carbon 30. Nitrogen, Nitrite as N 49. Chromium, Hexavalent >8. 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 33. Phenol 52. Iron 70. Disk Deliverables 14. Solids, Settleable 15. Solids, Suspended 34. Phosphorus Total as P 53.Lead ICLE 16. Solids, Total 35. Phosphorus, Ortho as P 54 Magnesium 71 TCLP-Metals 17. Solids, Total Dissolved 36. Sulfates 55 Manganese 72.TCLP-Pesticides 18. Solids, Total Volatile 37. Surfactants 56. Mercury 73.TCLP-Herbicides 19. Other:_________________ 38. UV254 57 Molybdenum / 74. TCLP-Volatiles 58. Nickel 75.TCLP-BNA’S

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