Chain of custody form, Westchester County Labs

NYC 9/11 Public Portal Document Westchester gov.com ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914) 593-5575 /Date Set: Sample Type (circle one): 1 Potable 3. Non Potable Treated 2. Non Potable* 4. Other Time/Date Collected: 0850/10-18-01 Collected By: Wagner Agency Code: Collected From: Location's/Individual's Name NYC DEP Street 19 WestLake Denve City/svzip_Valhalla, NY 10595 Identification of Source Collection Point_Del 18 NYS-ELAP No. 10108 Form A-70 (rev.1/96) p.1277 P807317 K6261, 4600a x 4378 Bottle #'s: C0222 02.957 QY6N 39258 P-18 Chain of Custody? _ yes no Comments: PWS #: Source ID: aType Descriptor: Bill to: Name/Company Street City/St/Zip Phone#: Fax#: CA,CH, BI? Check#: Amount$ BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS Lab#: (circle tests) 1. Heterotrophic Plate Count (hemodialysis & all others) 2. Coliform P/A (public supplies) 3. Coliform MPN (priv well, raw, stp) 4. Fecal Coliform (all samples) 5. Microscopic 6 Macroscopic 8. Other: Refrigerated? Chlorinated:2 yes no Free Chlorine Res: Total Chlorine Res:2 →yes - по 2mg/L mg/L рH Lab#: (circle tests) Trihalomethanes (524) 2, Volatile Halocarbons (524) Volatile Aromatics (524) 4. Total Trihalomethane Potential (510) 5. Microextractables (504) 6. Pesticides (507) 7. Pesticides/PCB screen (508) 8. PCB as Decachlorobiphenyl (508A) 9. Herbicides (515) (10. Pesticides (525) 11. Carbamate Pesticides (531) 12. Giyphosate (547) 13. Diquat (549) 14. Chlorination Disinfection Byproducts (551) 15. Haloacetic Acids (552) 16. Pesticides (SM18/6630) 17. Petroleum/Hydrocarbon Scan (310-13) 18. Other: 1. Purgeable Halocarbons (624/8260) 2. Purgeable Aromatics (624/8260) 3. Acrolein & Acrylonitrile (624) 4. Phthalates (625/8270) 5. Organochlorine Pesticides (608/8081) 6. PCB's (Arochlors) (608/8081) 7. Methoprene (616) 8. Herbicides (EPA1978/8151) 9. Pesticides (SM18/6630) 10. Petroleum Hydrocarbon Scan (310-13) 11. Glycols 12. Acid Extractables (625/8270) 13. Base Neutral Extractables (625/8270) (14, GC/MS Semivolatile Unknown Scan 15. Purgeable Halocarbons (DEF) 16. Purgeable Aromatics (DEF) 17. Pesticides/PCB's (DEF) 18. Other: INORGANIC ANALYSIS REQUESTED - Lab#: (circle tests) 1. Color 20. Acidity 2. Turbidity 21. Alkalinity, as CaCOз 3. рH 22. Bromide 4. Conductivity 23. Bromate/Chlorate/Chlorite 5. Corrosivity (temp) °C) 24. Chloride 6. BOD (5 day) 25. Cyanide 7. Soluble BOD (5 day) 26. Fluoride 8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCO3 9. Chemical Oxygen Demand 28. Nitrogen, Ammonia as N 10. Dissolved Oxygen 29. Nitrogen, Nitrate as N 11. Total Organic Carbon 30. Nitrogen, Nitrite as N 12: Total Organic Halides 31. Nitrogen, Total Kjeldahl as N 13. Solids, Percent (%) 32. Oil an Grease Solids, Settleable 33. Phenol #Solids, Suspended 34. Phosphorus Total as P 16. Solids, Total 35. Phosphorus, Ortho as P 17. Solids, Total Dissolved 36. Sulfates 18. Solids, Total Volatile 37. Surfactants 19l Other: sn, lı 38. UV254 39. Aluminum mutals 59. Potassium 40) Antimony 60. Selenium 41. Arsenic 61. Silver 42. Barium 62. Sodium 43 Beryllium 3! Thallium 44. Boron 64/ Vanadium 45. Cadmium 65. Zinc 46. Calcium, as CaCO3 CLP 47. Calcium, Ca+2 66. Metals/CN 48. Chromium, Total 67. Volatiles 49. Chromium, Hexavalent 68. Semi-violatiles 50 Cobalt 69. Pesticides/PCB's 51. Copper 70. Disk Deliverables 52. Iron 53.Lead TCLP 71.TCLP-Metals 54 Magnesium 72. TCLP-Pesticides 55 Manganese 73. TCLP-Herbicides 56. Mercury 57 Molybdenum 14. TCLP-Volatiles 58. Nickel 75. TCLP-BNA'S NYC-WTC_000072582