Chain of custody form, Westchester County Labs, Oct 2001

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM tester nov.com WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road. Valhalla. New York 10595 I. (914) 593-5575 . NYS-ELAP No. 10108 Tiai/Date Set: Sample Type (circle one): Bottle /s:- - _______________ T^otable 3. Non Potable Treated 2. Non Potable 4. Other Chain of Custody? yes no Time/Date Collected:> • T • V / Comments: Collected By: /Y- AO Agency Code: PWS #:______ _ Source ID: Type Descriptor: Collected From: Location’s/lndividual’s Name U UXV'! ' , Name/Company Street_____________________________________ ; Street . - X;. ’ ■ ■ City/St/Zip__________________________________ City/St/Z,p^ Identification of Source ■ ;_______ Phon^ Fax#: Collection Point________ S Check#: . Amounts ' "

BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS jO .ORGANIC NONPOTABLBS^oElC^ANALYSiS Lab#:_______________________ .Lab#: -Y ~ ' (circle tests) (circle tests) ’ ' .. 1. Heterotrophic Plate 11 Trihalometh'anes (524) ‘ 1. Purgeable Halocarbonsk(624/8260) . Count (hemodialysis & all others) f2?j Volatile Halocarbons '(524) ’ 2. Purgeable Aromatics (624/8260) 2. Coliform P/A (public supplies) \3/ . 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 PesticicfeT,(608/8081) 5. Microscopic e; Pesticides (507) . 6. PCB's (Arochlors) (608/8081) ’ 6. Macroscopic ■7.; Pesticides/PCB screen (508) 7. Methoprene (616) . 4 7. 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPAI 978/8151) 8. ^^r: 9. Herbicides (515) 9. Pesticides (SMI8/6630) ■ (^ Pesticides (525) , ,- 10. Petroleum Hydrocarbon Scan (310-13) Refrigerated? yes no Tl Carbamate Pesticides (531) 11. Glycols Chlorinated:? yes___ no 12. Glyphosate (547) 12. Acid Extractables (625/8270) . 13. Diquat (549) 1.3^ 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 (SM18/6630) 16. Purgeable Aromatics (DEF) ‘ pH 17. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB’s (DEF) i' C:- ■— 18. Other:__________________________ 18. Other:______________ t INORGANIC ANALYSIS REQUESTED - Lab#: (circle tests) 1. Color 20. Acidity 39. Aluminum'^ ikCS 59. Potassium | I 2. Turbidity 21. Alkalinity, as CaCOa 40. Antimony 60. Selenium i 3. pH 22. Bromide 41. Arsenic 61. Silver 3 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 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 I^Mids, Settleable 33. Phenol 52. Iron 1 a^^ids, Suspended T<£LP 34. Phosphorus Total as P 53.Lead 71 TCLP-Metals 16. Solids, Total 35. Phosphorus, Ortho as P 54 Magnesium 55 Manganese 72.TCLP-Pesticides 17. Solids, Total Dissolved 36. Sulfates 56. Mercury. 73. TCLP-Herbicides 18. Solids, Total Volatile 37. Surfactants 74. TCLP-Volatiles 19. Other:_________________ 38. UV254 57 Molybdenum 75.TCLP-BNA’s 58. Nickel

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