Chain of custody record for Westchester County Department

NYC 9/11 Public Portal Document - /.v.'v<’

■.'W ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM sster ovcom WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 . NYS-ELAP No. 10108 Time/Date Set: , Form A-70 (fev.10/dl)

Sample Type (circle one): 'i Y'/ 1. Potable 3. Non Potable Treated Bottle #’s: 2. Non Potable 4. Other .,. Chain of Custody? Yes_Y/No I Time/Date Collected: ' ■ /-S' AM Comments: Collected By: Agency Code: ? - PWS #: ' Source ID: 7 - Type' Descriptor’^ Collected From: Location's/lndividual’s Name : <36 : Name/Company _ t Street_________________ Street _________ City/St/Zip______________ City/St/Zip Identification of Source . - Phone#: _____ Fax#: Collection Ppint_________ l i .CA.Ct^. Bl? 3? ■: :Amouht$^<tgxtMi ••ft

BACTERIOLOGICAL ANALYSIS Lab#:_______________________ t __ Heterotrophic Plate Count ORGANIC POTABLE ANALYSIS/ 6; ’i_Trihalomethanes (524) (hemodialysis & all others) __ Coliform P/A (Public supplies) _ Volatile Halocarbons (524) Purgeiable'Aromatics (624/8260) ■ __ Coliform MPN (priv well, raw, stp) __ Volatile Aromatics (524) _ Acrolein &^i7lonitnle3b26b) ■ • ;/ <6’ __ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) ■ Organochiorine Pesticides (608/8081) ; __ Microscopic __ Microextractables (504) , ' Yj PCB’s;(Arochi6re)1 ^08/8081) ’ ;: ' __ Macroscopic __ Pesticides/PCB screen (508) Herbicides (SMI8/6630^8151) '' / _ API __ PCB as Decachlorobiphenyl (508A) i_ Other Pesticide; (SMI8/6630) . V' , _ Other:____________________ __ Herbicides (515) __ Petroleum'Hydrocarbon Scan (310-13) __ , Pesticides (525) ' __ Glycols in Water ■ Refrigerated?yes no __ Carbamate Pesticides (531) _ Acid Extractables;(625/8270) . ' 4^ Chlorinated:?yes no __ Glyphosate (547) __ Base Neutral Extractables (625/8270) ■, '6 _ Diquat (549) __ GC/MS Unknown Scan Free Chlorine Res: . mg/L __ Chlorination Disinfection Byproducts (551) _ Phthalates'(6b6MS) Total Chlorine Res: . mg/L __ Haloacetic Acids (552) _ Other: _ Other Pesticides (SMI8/6630) ' pH ___________ _UCMRList1 RADIOCHEMICAL ANALYSIS _ MtBE Only (524) Radon __ Other_________________ __

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Acidity 21: Aluminum __ Potassium __ Turbidity __ Alkalinity __ Antimony _*<6elenium Zj; — pH __ Bromide _ Arsenic __ Conductivity __ Corrosivity (temp: .’C) __ Bromate/Chlorate/Chlorite __ Chloride Barium ' ' _i Beryiiium"‘ . '■ _l>Thallium ” a® t./i-y Y _ BOD (5 day) __ Cyanide _ Boron • __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium _ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOs __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*2 __ Dissolved Oxygen __ Nitrogen, Nitrate as N __Chromium, Total _ Metals/CN __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Volatiles __ Chromium, Hexavalent __ Semi-violatiles ' __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N __ ; Cobalt __ Solids, Percent (%) __ Oil and Grease __ Pesticides/PCB's —^Copper __ Solids, Settleable __ Phenol __ Iron __ Solids, Suspended TCLP __ Phosphorus Total as P _2.'Lead __ Solids, Total __ Phosphorus. Ortho as P 2_TCLP-Metals Magnesium __ Solids, Total Dissolved TCLP-Pesticides __ Sulfates , _;i‘Manganese __ Solids, Total Volatile __ Surfactants _ TCLP-Herbicides . Mercury J_ Other:______ :__________ _ UV254 ^Molybdenum __ TCLP-Volatiles _TCLP-BNA’s .JrNickel

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