Chain of custody form, Westchester County Labs, Oct 2001

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ;ster WESTCHESTER COUNTY LABORATORIES AND RESEARCH iv.com 2 Dana Road, Valhalla, New York 10595 (914) 593-5575 C - 0.^6*^ NYS-ELAP No. 10108 r^j^Date Set: <3 - G , (rev.1/96) Sample Type (circle one): 1. Potable 3. Non Potable Treated Bottle rs: 2. Non Potable 4. Other j___ t Chain of Custody? yes no Time/Date Collected: h\ ■ Comments: Collected By:_____ ; Agency Code: PWS #:________ Source ID: Type Descriptor: Collected From: Bill to: ■T' -Ltt 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#: ^;An^unt$j2Y5ri^ A

BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS V. Lab#: ' ' Lab#; \ • || (circle tests) 1. Heterotrophic Plate , (circle teste) (^ 1; Trihalomethanes (524) ■ ’ • www ><. Purgeable Haiocarbons'/(624/8260)_vV;: ,/<,- Count (hemodialysis & all others) -.Volatile Halocarbons (524) 2. Purgeable Aromatics (6^26b) v ^\iY '■ 2. Coliform P/A (public supplies) \J3/Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624) 3. Coliform MPN (priv well, raw, stp) 4. Total Trihalomethane Potential (510) 4. Phthalates (625«270)-B 4. Fecal Coliform (all samples) 5^ Microextractables (504) 5. Organochlorine Pesticides’(608/86&V 5. Microscopic ' 6^ Pesticides (507) 6. PCB's (Arochlors) (608/8081) S' 6. ^^roscopic , 7J Pesticides/PCB screen (508) 7. Methoprene(616) ' 3.’^; 7. 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151) ? . 8. ^mer: 9. Herbicides (515) 9. Pesticides (SM18/6630) ' da Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13) Refrigerated? yes no it Carbamate Pesticides (531) 11. Glycols ■ "T; 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) 1. Color 20. Acidity 39. Aluminum ■ 59. Potassiurn 2. Turbidity 21. Alkalinity, as CaCOs 40. Antimbny 60. Selenium 3. pH 22. Bromide 41. Arsenic 61. Silver J 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. Boron 64. Vanadium' 7. Soluble BOD (5 day) 26. Fluoride 45. Cadmium 65. Zinc j 8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOs 46. Calcium, as CaCOa 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 1|«^lids, Settleable 33. Phenol 52. Iron TCLP ll^Llids, Suspended 34. Phosphorus Total as P 53.Lead 71 TCLP-Metals 16. Solids, Total 35. Phosphorus, Ortho as P 54 Magnesium 72.TCLP-Pesticides .Y • 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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