Chain of custody form, Westchester County Labs, Oct-Nov 2001

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ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM • '■ • • ■ rji ;

r- I Hester gov.com WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 1 (914) 593-5575 NYS-ELAP No. 1 Time/Date Set: Form A-70 (rev.1

Sample Type (circle one): 1. Potable' 3. Non Potable Treated Bottle #’s: —,________ _____ • ■/

4. Other____________ Chain of Custody? 'ZJ^s rio / 2. Non Potable Time/Date Collected: Comments: Collected By: Agency Code: PWS #:______ Source ID; Type Descriptor: Collected From: Bill to: Location’s/lndividual’s Name Name/Company Street_________________ Street_______ City/St/Zip______________ City/St/Zip Identification of Source Phone#: Fax#: Collection Point' Amounts. CA,CH, Bl? Check#:

BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS Lab#:______________________ Lab#:________________________ (circle tests) (circle tests) 1. Heterotrophic Plate 1. Trihalomethanes (524) 1. Purgeable Halocarbons, (624/8260) Count (hemodialysis & all others) Volatile Halocarbons (524) '2. Purgeable Aromatics (624/8260) 2. Coliform P/A (public supplies) Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624) 3. Coliform MPN (priv well, raw, stp) 4. Total Trihalomethane Potential (510) 4. Phthalates (625/8270) 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) 7. API a PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPAI 978/8151) C, 8. Other; _ ___________________ 9, Herbicides (515) 9. Pesticides (SMI 8/6630) -■ (10,.^ Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13) Refrigerated?yes___ no 11. Carbamate Pesticides (531) 11 .Glycols Chlorinated:?yes no 12. Glyphosate (547) 12.\AcidExtractables (625/8270) 13. Diquat (549) 1g. Base Neutral Extractables (625/8270) Ree Chlorine Res: mg/L 14. Chlorination Disinfection Byproducts (551) ... WGC/MS Semivolatile Unknown Scan 15. Haloacetic Acids (552)•< ,^ Purgeable,Halocarbons (DEF) ' ... Total Chlorine Res: mg/L 16. Pesticides (SM18/663p)t4^L ,/ ^J^e^Purge^^rpmatics (DEF) ... 17. Petroleum/Hydrocarbon Scan (31O-13)£,X.. 17. Pesticides/PCB’s (DEF) :. ( , t; 18. Other:^^^VL^OB—W%8“Other411;±^^fejL412L^

INORGANIC ANALYSIS REQUESTED - Lab#; (circle tests) 7 1. Color 20. Acidity 39. Aluminum 59 Potassium ■ V’ 2. Turbidity 3. pH 4. Conductivity 21. Alkalinity, as CaCOs 22. Bromide 23. Bromate/Chlorate/Chlorite 40. Antimony 41. Arsenic 42. Barium’ 60. Selenium 1 61. Silver 62. Sodium ’ I 5. Corrosivity (temp:, “C) 24. Chloride 43. Beryllium 63. Thallium ‘ 6. BOD (5 day) 25. Cyanide 44. Boron 64. Vanadium j 7. Soluble BOD (5 day) 26. Fluoride 45. Cadmium 65. Zinc ! 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*^ 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£LB 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 74. TCLP-Volatiles 19. Other:_________________ 38. UV254 . 57 Molybdenum' 75.TCLP-BNA’s 58. Nickel ‘..........................

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