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 tv.com 2 Dana Road, Valhalla, New York 10595 - (914) 593-5575 NYS'-ELAP No. 10108 Tgipate Set: Form A-70 (rev. 1/96)

Sample Type (circle one): 14 • 4?Potable 3. Non Potable Treated Bottle #’s: ur? 6 7^ . S 4044-4^1 o . 2. Non Potable 4. Other Chain of Custody?___ yes no Time/Date Collected:' ' -- I2.0 12ool Comments: Collected By: A Agency Code: PWS #:_______ Source ID: Type Descriptor: Collected From: Bill to: Location’s/lndividual’s Name o.Qn Name/Company. Street________ ______________________ Street________ City/St/Zip_______________________ ' City/St/Zip Identification of Source ______ - Phone#: Fax#: Collection Point I CA.CH, Bl? Check#: ' Am'ount$ -Y . "

BACTERIOLOGICAL ANALYSIS ■ ORGANICPOTABLE ANALYSIS ORGANIC NONPOTABLE/SOUD ANALYSIS Lab#: __ n < (circle tests) Q | xy (circle tests) , ; ; .•s 1. Heterotrophic Plate 'l/ Trihalomethanes (524) 1. Purgeable Halocarbons . (624/8260) Count (hemodialysis & all others) ^2?j 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. j^H^oscopic v 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) (ia) Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13) Refrigerated? yes, no Tt. 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#: I' (circle tests) 1. Color 20. Acidity ----- VW (to. I 39. Alumigum ' 59. Potassiurri C? 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 . 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 13^0lilids, Percent (%) 32. Oil an Grease 51.Copper 70. Disk Deliverables |lids, Settleable 33. Phenol 52. Iron TCLP isWbilids, 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 58. Nickel

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