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

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM hester ^:com WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914) 593-5575

Time/Date Set: NYS-ELAP No. Form A-70 (rev. w Sample Type (circle one): / 1potable 3. Non Potable Treated Bottle #’^

'’2. Non Potable 4. Other Chain of Custody? yes___ no Time/Date Collected: Comments: Collected By: Agency Code: PWS #:________ Source ID: Type Descriptor: Collected From: Bill to: Location’s/lndividual’s Name jAli Name/Company _ Street_____________________ Street_________ City/St/Zip__________________ City/St/Zip Identification of Source Phone#:_______ Fax#: Collection Point Qv’ Amounts. CA.CH, Bl? Check#:

BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLEZSOLID ANALYSIS Lab#:_______________________ ^b#:________________________ (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. Organochloririe Pesticides (608/8081) 5. Microscopic ‘ 6.. Pesticides (507) 6. PCB’s (Arochlors) (60^8081) . 6. Macroscopic Pesticides/PCB screen (508) 7. Methoprene (616) . v. 7..API '5- PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPAI 978/8151) r 8. Other:____________________ Herbicides (515) 9.-Pesticides (SMI 8/6630)^** Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13) / Refrigerated? yes no 11. Carbamate Pesticides (531) 11. Glycols . Chlorinated:? yes no 12. Glyphosate (547) 12. Acid Extractables (625/8270) ____ 13. ___ _ (549) Diquat _ .. M l ,; 13. Base NeutrafE)rtractables (625/827m Free Chlorine Res:. mg/L 14. Chlorination Disinfection Byproducts (Ml)^n^ GC/MS Semivolatile Unknown Scan ! Total Chlorine Res: mg/L 15. Haloacetic Acids (552) 'r, ' Eurgeable Halbcarbons (DEF)j , 16. Pesticides (SMI8/6630) t . A , >5j6\.Purgeable Aromatics (DEF)? "/ ‘ .i tZ. . ,17. Petroleum?Hydrocarbon Scan (310^,13),> :)J^7^e^cides/PC^;s';(DEF)

INORGANIC ANALYSIS REQUESTED - Lab#: (circle tests) ■

1. Color 20. Acidity 39. Aluminum 'J 59. ^Potassium 2. Turbidity 21. Alkalinity, as CaCOa 40. Antimony '.. /.’ 60. Selenium 3. pH 22. Bromide 41. Arsenic , 61. Silver 23. Bromate/Chlorate/Chlorite 42. Barium / Y . 62. Sodium 4. Conductivity 5. Corrosivity (temp: .®C) 24. Chloride 43. Beryllium 63. Thallium 1 6. BOD (5 day) 25. Cyanide 44. Boron 64.,yanadium 7. Soluble BOD (5 day) 26. Fluoride 45. Cadmium vi_ 65. Ziric 8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOa 46. Calcium, as CaCOs CLP 9. Chemical Oxygen Demand 28. Nitrogen, Ammonia as N 47. Calcium, Ca*2 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 TCLP 15. Solids, Suspended 34. Phosphorus Total as P 53.Lead 54 Magnesium 71 TCLP-Metals 16. Solids, Total 35. Phosphorus, Ortho as P 72.TCLI’-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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