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 ivcom 2 Dana Road, Valhalla, New York 10595 (914) 593-5575 NYS-ELAP No. 10108 ate Set: Form A-70 (rev. 1/96) ■ ■ - A . Sample Type (circle one): 1; Potable ' 3. Non Potable Treated Bottle rs: iWL 2. Non Potable 4. Other_________________________ Chain of Custody?___ yes no Time/DateCollected: ( O .Z Comments:__________________ Collected By: Agency Code: PWS #:______ Source ID: Type Descriptor: Collected From: Bill to: Location’s/lndividual’s Name "^1? oM - ' Name/Company Street 1 Street_____ __ City/St/Zip__________ _ ______________ City/St/Zip Identification of Source Phone#: Fax#: Collection Point _ CA,CH, Bl? Chgck#: Amounts__ -

BACTERIOLOGICALANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLIDANALYSIS Lab#: > (circle tests) (circle tests) 1. Heterotrophic Plate ’ , . 1.'Trihalomethanes ;(524) ■ / 1. Purgeable Halocarbons (624/8260) Count (hemodialysis & all others) '^ 2/ Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260) 2. Coliform P/A (public supplies) O; Volatile Aromatics' (524) 3. Acrolein & Acrylonitrile (624) 3. Coliform MPN (priv well, raw, stp) 4. Total Tri halo methane Potential (510) 4. Phthalates (625/8270) ’'1 4. Fecal Coliform (all samples) 5., Microextractables (504) 5. Organochlorine Pesticides' (608/8081)' 5. Microscopic ' ’a Pesticides' (507) 6. PCB’s (Arochlors) (608/8081) ' ' 6. U||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 (SMI 8/6630) 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) X3< Base Neutral Extractables (625/8270) . Free Chlorine Res:. mg/L 14. Chlorination Disinfection Byproducts (551) (J4'. GC/MS Semivolatile Unknown Scan 15. Haloacetic Acids (552) ^15. Purgeable Halocarbons (DEF) Total Chlorine Res: mg/L 16. Pesticides (SM18/6630) 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. Alurnipum ' ' f-fl IS 1. Color 20. Acidity 59. Potassium 2. Turbidity 21. Alkalinity, as CaCOs 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 CaCOs 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 l^^lids. Settleable 33. Phenol 52. Iron TCLP inKlids, 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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