Chain of custody record for Westchester County Department

NYC 9/11 Public Portal Document

I ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ster WESTCHESTER COUNTY LABORATORIES AND RESEARCH ivcom 2 Dana Road, Valhalla, New York 10595 /1 (914)231-1620 Fax (914) 231-1772 NYS-ELAP No. 10108 ‘ Time/Date Set: Form A-70 (rev: 10/01)

Sample Type (circle one): . 1. Potable 3. Non Potable Treated Bottle #’s: 2. Non Potable 4. Other____________ Chain of Custody? Yes No Time/Date Collected: ■ .7 Comments: Collected By: ' Agency Code: PWS #:________ Source ID: Type Descriptor: Collected From: Bill to: Location’s/lndividual’s Name Name/Company _ Street__________________ Street_________ City/St/Zip______________ City/St/Zip Identification of Source . Phone#: Fax#: Collection Point <- |/CA,CH,B1? Check#: Amount$

BACTERIOLOGICAL ANALYSIS Lab#: i Lab#:_______________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count (hemodialysis' & all otfiers) __ Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) __ Coliform P/A (Public supplies) __ Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform MPN (priv well, raw, stp) _ Volatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) __ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) __ Org'anochlorine Pesticides (608/8081) __ Microscopic . Microextractables (504) ■ _ PCB’s (Arochlors) (608/8081) 2 Pesticides/PCB screen (508) Herbicides (SM18/6630,8151) __ Macroscopic _ API JR PCB as Decachlorobiphenyl (508A) ' _ Other Pesticides (SMI8/6630) SHerbicides (515) __ Petroleum Hydrocarbon Scan (310-13) __ Other:_____________________ ZP’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) __ 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 (SMI8/6630) pH ___________ _UCMRList1 RADIOCHEMICAL ANALYSIS _ MtBE Only (524) J__ Radon __ Other____________________

> INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Acidity Aluminum __ Potassium, / > y __ Turbidity _ Alkalinity Antimony Selenium'" ? •- r _ pH __ Bromide __ Arsenic - Silver __ Conductivity __ Bromate/Chlorate/Chlorite Barium __ Sodium __ Corrosivity (temp:. .’C) __ Chloride t- ■ Beryllium _Z_ Thallium > _ BOD (5 day) __ Cyanide __ Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium Zinc __ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOa __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*^ GLE _ Metals/CN __ Dissolved Oxygen __ Nitrogen, Nitrate as N jL_Chromium, Total __ Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Semi-violatiles ,__ Total Organic Halides __ Nitrogen, Total Kjeldahl as N j:_ Cobalt __ Pesticides/PCB’s '__ Solids, Percent (%) __ Oil and Grease . __ Copper __ Solids, Settleable __ Phenol __ Iron _ Solids, Suspended __ Phosphorus Total as P __ Lead ICkE _TCLP-Metals __ Solids, Total __ Phosphorus, Ortho as P __ Magnesium __ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates _ifManganese __ TCLP-Herbicides __ Solids, Total Volatile __ Surfactants vHVIercury _ TCLP-Volatiles __ Other: ________ _ UV254 _t^olybdenum _ TCLP-BNA’s (/fiickel

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