Chain of custody form, Westchester County Labs, Oct 2001

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ster 3av.com 'ate Set: WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914) 593-5575 H NYS-ELAP No. 10108 Form A-70 (rev.1/96)

Sample Type (circle one): (pPotable 3. Non Potable Treated Bottle #’s:_____________________________________ J_______ 2. Non Potable 4. Other Chain of Custody?___ yes no Time/Date Collected: Comments:_____________________________ 2_____________ Collected By: Agency Code: PWS #:______ Source ID: Type Descriptor: Collected From: Bill to: tv’- “• Location’s/lndividual’s Name__________________________ Name/Company Street __ ________ ________________ :______________ Street________ Citv/St/Zip . X _________ City/St/Zip Identification of Source ■ Phone#; Fax#: Collection Point r *? x ,t^i>} - CA,CH, Bl? Check#; Amounts if" , .

BACTERIOLOGICAL^NALY^S ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLIDANALYsis" Lab#: ... (_. (circle tests) (circle tests) 1. Heterotrophic Plate . Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260) Count (hemodialysis & all others) f,2.<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. Organochlorine Pesticides (608/8081) ; 5. Microscopic .6,, Pesticides (507) 6. PCB's (Arochlors) (608/8081) 6. ^croscopic (,7,’ Pesticides/PCB screen (508) 7. Methoprene (616) 7. 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPAI 978/8151) 8. ^mer: ,9^, Herbicides (515) 9. Pesticides (SMI 8/6630) Refrigerated?yes___ no Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13) 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) 1. Color 20. Acidity 39. Alurninum i 59. Potassium; 2. Turbidity 21. Alkalinity, as CaCOa 40. Antimony 60. Selenium 3. pH 22. Bromide 41. Arsenic 61. Silver \ 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 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 14g||lids, Settleable 33. Phenol 52. Iron ll^llids. Suspended 34. Phosphorus Total as P 53.Lead TCLP. 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 58. Nickel

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