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

NYC 9/11 Public Portal Document - ... . s............... ^^7

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM jester WESTCHESTER COUNTY LABORATORIES AND RESEARCH wv.com 2 Dana Road, Valhalla, New York 10595 (914) 593-5575 Vr- NYS-ELAP No. Time/Date Set: F^m A-70 (rev.

Sample Type (circle one): ^/^otable 3. Non Potable Treated Bottle '-.g' - ?z- 2. Non Potable 4. Other Chain of Custody? _ yes___ no / Time/Date Collected: — -■f- / Comments: Collected By:------ --- ----------------- Agency Code; PWS #;_________ Source ID: Type Descriptor: Collected From: BUI to: Location’s/lndividual's Name Name/Company Street_________________ Street__________ City/St/Zip______________ City/St/Zip Identification of Source Phone#:________ Fax#: Collection Point < CA,CH, Bl? Check#; Amounts.

BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS Lab#:_______________________ Lab#:________________________ (circle fests) (circle tests) 1. Heterotrophic Plate 1. Trihalomethanes (524) ,T. Purgeable Halocarbons/(624/8260) Count (hemodialysis & all others) 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) 4. Total Trihalomethane Potential (510) 4. Phthalates (625/8270) - 4. Fecal Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticide^* (608/8081 5. Microscopic • 6. Pesticides (507) 6. PCB’s (Arochlors) (608/8081) 6. Macroscopic ' Pesticides/PCB screen (508) . 7. Methoprene (616) ' 7. API .* , ■PCB as Decachlorobiphenyl (508A) , . \8. Herbicides '(EPA1978/8151) 8. Other:__________ ■ • - - • 9. Herbicides (515) - ’9. Pesticides'(SMi8/6630) (^(Pesticides (525) 10.. Petroleum Hydrocarbon Scan (310-13) Refrigerated?yes no T< Carbamate Pesticides (531) 11. Glycols Chlorinated;? yes no 12. Glyphosate (547) 12. Acid Extractables '(625/8270) 13. Diquat (549) . Y. 13.: Base Neutral Extra^^les (625/8270) Free Chlorine Res;. mg/L 14. Chlorination Disinfection Byproducts (551) -'Iv (TOgC^S Sdmivolatile’Unknown Scan 15. Haloacetic Acids (552) -.-’'hvlK Purgeabl^^^^^^ • Total Chlorine Res:

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INORGANIC ANALYSIS REQUESTED - Lab#; - ^^Alfeumiy'^-^l^ - '59. Potl^ium (circle tests) 1. Color • W' 20. Aridity K.. 2. Turbidity 21. Alkalinity, as CaCOs ? 40. Antimony • ; 60. Selenium 3. pH 22. Bromide 41. Arsenic ' ■ J 61. Sliver 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. Borori K 64. Vanadium 7. Soluble BOD (5 day) 26. Fluoride 45. CadmiuftmX* 65. Zinc 8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOa 46. Calcium, as CaCOs GLE 9. Chemical Oxygen Demand 28. Nitrogen, Ammonia as N 47. Calcium, Cat® 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 15. Solids, Suspended 34. Phosphorus Total as P 53.Lead I£LB 71 .TCLP-Metals 16. Solids, Total 35. Phosphorus, Ortho as P 54 Magnesium , 55 Manganese « 72.TCLP-Pesticides 17. Solids, Total Dissolved 36. Sulfates 56. Mercurys' 73.TCLP-Herbicides 18. Solids, Total Volatile 37. Surfactants 74. TCLP-Volatiles 19. Other:_________________ 38. UV254 57 Molybdenum 75. TCLP-BNA’s 58. Nickel

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