Chain of custody record for Westchester County Department

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM sster WESTCHESTER COUNTY LABORATORIES AND RESEARCH Dvcom 2 Dana Road, Valhalla, New York 10595 O/ ■ _ I -4 < UAJIsiHBhdKaMJ X (914)231-1620 Fax (914) 231-1772 NYS-ELAP No. 10108 ' Time/Date Set: Form A-70 (rev. 10/01) •Y ,, Sample Type (circle one): Bottle '/ C/. 1. Potable 3. Non Potable Treated 2. Non Potable 4. Other____________ Chain of Custody?___ Yes No Time/Date Collected: 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/SVZip Identification of Source Phone#: Fax#: Collection Point ------------------------------ I CA,CH, Bl? Check#: Amounts I

BACTERIOLOGICAL ANALYSIS Lab#: - : 'i Z'") Lab#:_______________________ f / / 0 U Cz ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count _Trihalomethanes (524) (hemodialysis & all others) __ 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) __ Organochlorine Pesticides .(608/8081) __ Microscopic __ Microextractables (504) _ PCB’s (Arochlors) (608/8081) j' __ Macroscopic __ Pesticides/PCB screen (508) _ Herbicides (SMI8/6630,8151) _ 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) _iX'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 (SM18/6630) pH ___________ _ UCMR List 1 RADIOCHEMICAL ANALYSIS _ MtBE Only (524) __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ /k:idity _ Aluminum' __ Potassium __ Turbidity __ Alkalinity __ Antimony __ Selenium _ 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 _ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOs __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*^ CLE _ Metais/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 TCLP __ Solids, Suspended __ 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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