Chain of custody form, Westchester County Labs, Oct 2001

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ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ster WESTCHESTER COUNTY LABORATORIES AND RESEARCH iv.com 2 Dana Road, Valhalla, New York 10595 (914) 593-5575 NYS-ELAP No: 10108 r^^Date Set: Form'A-70 (rev.1/96)

^_mple Type (circle one): ■-1. Potable 3. Non Potable Treated Bowe "’JY, i t 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 u/a.-______________________ Name/Company Street_________________________ _______________________ Street________ City/St/Zip_______________________ 2^___________ City/SVZip Identification of Source ~ Phone#: Fax#:_£sS_2 Collection Point ^210^ I CA,CH, Bl? Check#;.£2ii±!lS_^Amount$i^j^;i2^^-

BACTERIOLOGICAL ANALYSIS -" ORGANIC POJABt^ /^LY^IS J ORGAN, Lab#:.^_________ (circle tests) (circle tests) Y O J j 1. Heterotrophic Plate 1. ,Trihalomethanes (524) 1. Purgeable Halocarbons'•(624/8260) Count (hemodialysis & all others) Volatile Halocarbons (524) 2. Purgeable Aromatics (624/826()p Y 2. Coliform P/A (public supplies) \3-' Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624r ■./<,, f 3. Coliform MPN (privwell, raw,stp) 4. Total Trihalomethane Potential (510) 4. Phthalates (625/8270) ’^3’" 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. M^roscopic (7/ Pesticides/PCB screen (508) 7. Methoprene (616) 7. 8. 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 11. 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. Chlorination Disinfection Byproducts (551) (14?GC/MS Semivolatile Unknown Scan Total Chlorine Res: mg/L 15. Haloacetic Acids (552) 15. Purgeable Halocarbons (DEF)' . 16. Pesticides (SMI8/6630) 16. Purgeable Aromatics (DEF) pH 17. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB’s (DEF) 18. Other:__________________________ 18. Other:__________________________

INORGANIC ANALYSIS REQUESTED - Lab#: (circle tests) ----- 39. Aluminum S y 59. PotassiurT) 1. Color 20. Acidity 2. Turbidity 21. Alkalinity, as CaCOa 40. Antimony 60. Selenium ; 3. pH 22. Bromide 41. Arsenic 61. Silver j 4. Conductivity 23. Bromate/Chlorate/Chlorite 42. Barium 62. Sodium i 5. Corrosivity (temp:. ’C) 24. Chloride ’ 43. Beryllium 63. Thallium • 6. BOD (5 day) ■ 25. Cyanide 44. Boron 64. Vanadiurri 7. Soluble BOD (5 day) 26. Fluoride 45. Cadmium 65. zinc ; 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*^ 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 t^klids. Settleable 33. Phenol 52. Iron TCLP iWRlids, Suspended 34. Phosphorus Total as P 53.Lead 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 , 'S 58. Nickel

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