Chain of custody form, Westchester County Labs, Oct 2001

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM lester [ov.com WESTCHESTER COUNTY LABORATORIES AND RESEARCH ’J 2 Dana Road, Valhalla. New York 10595 '■i

, (914) 593-5575 NYS-ELAP No. 10108 Form A-70 (rev.1/96)

SarnpleType (circle one): .xffPotable 3. Non Potable Treated Bottle #’s: 2. Non Potable 4. Other Chain of Custody? yes no Tlme/Date Collected:________ _________________ Comments: Collected By: Ag^cy Code: ■PWS #:________ Source ID: Type’Descriptor Collected From: , Bill to: Location’s/lndividual’s Name Name/Company Street__________ ._______ Street_________ A City/St/Zip __________ City/St/Zip r;'}

Identification of Source J__ : hfep#_ Phone#:_______ Fax#: ■;r.\ WJ—’i' ■ ./I Collection Point CA,CH, Bl? Check#:

BACTERIOLOGICAL ANALYSIS i); ORGANIC POTABLE ANALYSIS ORGANICNONPO«BLE^P|^^ Lab#: ■ ' ' ' ’ ’ , Lab#: zn f ____ (circle tests)' (circle tests) ^/^>> A‘-•J 1 , ,Trihalomethanes (524) St/sSfya/ 1. Purgeable Halocarbons ^^2f'8260)^;A;.; 1, Heterotrophic Plate Count (hemodialysis & all others) /•Z,\ Volatile Halocarbons (524) 2. Purgeable Aromatics (624/826d)’fe,A.>, ' 2, Coliform P/A (public supplies) ', 3,/Volatile Aromatics (524) 3. Acrolein & Acrylonitrile ,(624) ‘u 3, Coliform MPN (priv well, raw, stp) X: 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. M|croscopic ,;7,; Pesticides/PCB screen (508) 7. Methoprene (616) iv 7. 8;' PCB as Decachloroteiphenyl (508A) 8. Herbicides (EPAI 978/8151) q 8. Otner:_____ 9, Herbicides (515) 9. Pesticides (SMI 8/6630) ' rid’) Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13) Refrigerated?yes no Yf 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) ,Y4>GC/MS Semivolatile Unknown Scan 15. Haloacetic Acids (552) ^15. Purgeable Halocarbons (DEF) Total Chlorine Res: mg/L 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) [.4 1. Color 20. Acidity 39, Alurninum . . ' ' 59, Potassium ; 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 J 5. Corrosivity (temp:. 24. Chloride 43, Beryllium 63, Thallium : 6. BOD (5 day) 25. Cyanide 44, Boron ,64, Vanadium s 7. Soluble BOD (5 day) 26. Fluoride 45, Cadmium . *65, Zinc 8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOa# 46, Calcium, as CaCOa A 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 4^ Chromium, Hexavalent '' 68. Semi-violatiles 12.^Total Organic Halides * 3|dMitrogen, Total Kjeldahl as N 50; Cobalt ^9, Pesticides/PCB’s 13. Solids, Percent (^) 3^Oil an Grease 51,Copper ) '70. Disk Deliverables l^^lids. Settleable 33, Phenol 52, Iron iwRlids, Suspended 34, Phosphorus Total as P 53,Lead 35, Phosphoru?, Ortho as P 71 TCLP-Metals 16. Solids, Total 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 A . NYC-WTC_000072706