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

NYC 9/11 Public Portal Document

H ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM .lester WESTCHESTER COUNTY LABORATORIES AND RESEARCH eovcnm 2 Dana Road, Valhalla, New York 10595 (914) 593-5575 NYS-ELAP No. Time/Date Set: Form A-70 (rev.

Sample Type (circle one): ■ 1. Potable 3. Non Potable Treated Bottle #’s: ■, •" / 2. Non Potable 4. Other____________ Chain of Custody?___ yes no Time/Date Collected: f •- ! Comments:__________________ Collected By: J_ L' Agency Code: PWS #:_________ Source ID: Type Descriptor: Collected From: Bill to: Vocation’s/lndividual’s Name N^^/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) .'2?'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 (?) Pesticides/PCB screen (508) - ■ 7. Methoprene (616) 7. API s' PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPAI 978/8151) 8. Other:____________________ 9. Herbicides (515) -9. Pesticides (SMI8/6630) Pesticides (525). 10. Petroleum Hydrocarbon Scan (310-13) Refrigerated?yes no R Carbamate Pesticides (531) 11. Glycols Chlorinated:? yes no 12. Glyphosate (547) 12. Acid Extractables (625/8270) . 13. Diquat (549) . 13. Base Neutral Extractables (625/8270) Free Chlorine Res:. mg/L 14. Chiorination Disinfection Byproducts (551) il4^C/MS Semivolatile Unknown S^n 15. Haloacetic Acids (552) . . , IS Purgeable Halocarbons (DEF)'.!' . Total Chlorine Res: mg/L ■ 16. Pesticides (SMI8/6630)' -T* 16. Purgeable Arprriatics (DEF) 17. Petroleum/Hydrocarbcin Scari' (310-13) ^^* ^17. Pesticides/PCB’s (DEF) . 18. ■

INORGANIC ANALYSIS REQUESTED - Lab#: '(circle tests) ’ T. Color 20. Acidity 39. Aluminum ’ 59. Potassium 2. Turbidity 3. pH 21. Alkalinity, as CaCOa 22. Bromide 40. Antimony 41. Arsenic 60. Selenium 61. Silver 1 4. Conductivity 23. Brorriate/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 CaCOs 46. Calcium, as CaCOa CLE 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-vlolatiles 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 15. Solids, Suspended 34. Phosphorus Total as P 53.Lead ICLE 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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