Chain of custody record for Westchester County Department

NYC 9/11 Public Portal Document

I ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ster vcom WESTCHESTER COUNTY LABORATORIES AND RESEARCH r__Ji 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 u/ ■ \ -*

NYS-ELAP No. 10108 Time/Date Set: Form A-70 (rev. 10/01)

Sample Type (circle one): I f . . 1. Potable 3. Non Potable Treated Bottle #’s: '-V'z 2. Non Potable 4. Other _ __________ Chain of Custody?___ Yes No j Time/Date Collected:: ■ / ih.L Comments: • j"I ‘ Collected By: Agency Code: i 7 • i- V t PWS #:______ Source ID: Type Descriptor: Collected From: Bill to: , Location’s/lndividual’s Name U [ Hc Name/Company . Street_________________ Street________ City/St/Zip______________ City/St/Zip Identification of Source Phone#: Fax#: Collection Point I CA.CH, Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS Lab#:______ /' y Cz ^/ Lab#: ___ ____________________ ORGANIC potable ANALYSIS - ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count (hemodialysis & all others) __ Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) __ Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) __ Volatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) __ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) _ Organochlorine Pesticides (608/8081) __ Microscopic __ Microextractables (504) _ PCB’s (Arochlors) (608/8081) __ Macroscopic __ Pesticides/PCB screen (508) _ Herbicides (SM18/6630,8151) ■ API __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SMI8/6630) __ Other:_____________________ _ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) __ Pesticides (525) __ Glycols in Water Refrigerated?yes no __ Carbamate Pesticides (531) __ Acid Extractables (625/8270) Chlorinated:? yes no __ Glyphosate (547) __ Base Neutral Extractables (625/8270) __ Diquat (549) J_ GC/MS Unknown Scan Free Chlorine Res: . mg/L __ Chlorination Disinfection Byproducts (551) _ Phthalates (606MS) Total Chlorine Res: . mg/L __ Haloacetic Acids (552) __ Other:____________________________ _ Other Pesticides (SMI 8/6630) pH ------- ------------ _ UCMR List 1 RADIOCHEMICAL ANALYSIS _ MtBE Only (524) __ Radon __ Other_____________________

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Acidity __ Aluminum __ Potassium __ Turbidity __ Alkalinity __ Antimony __ Selenium ,//■ j _ pH __ Bromide __ Arsenic _ Silver ' __ Conductivity ■__ Bromate/Chlorate/Chlorite __ Barium __ Sodium __ Corrosivity (temp:. “C) __ Chloride __ Beryllium __ Thallium _ BOD (5 day) __ Cyanide __ Boron __ Vanadium ’ ■ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Zinc I Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOs __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*2 CLE __ Metals/CN __ Dissolved Oxygen __ Nitrogen, Nitrate as N __ Chromium, Total _ Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Semi-violatiles ■ Total Organic Halides __ Nitrogen, Total Kjeldahl as N _ Cobalt __ Pesticides/PCB's _ Solids, Percent (%) __ Oil and Grease __ Copper __ Solids, Settleable __ Phenol __ Iron __ Solids, Suspended ICi£ __ Phosphorus Total as P __ Lead _TCLP-Metals __ Solids, Total _ Phosphorus, Ortho as P __ Magnesium __ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates __ Manganese _TCLP-Herbicides __ Solids, Total Volatile __ Surfactants __ Mercury , _ TCLP-Volatiles __ Other:_________________ _ UV254 __ Molybdenum _ TCLP-BNA’s Nickel

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