Chain of custody record for Westchester County Department

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM I ster )vcom WESTCHESTER COUNTY LABORATORIES AND RESEARCH , 2 Dana Road. Valhalla. New York 10595 ■ " ' (914)231-1620 Fax (914) 231-1772 <I f- NYS-ELAP No' 10108 - Time/Date Set: FoiffiA-70(rev‘l()/6lj

Sample Type (circle one): ■ 1. F?otable 3. Non Potable Treafed Bottle #’s: * "" \ Is- ■ " 2. Non Potable 4. Other\ Chain of Custody?___ Yes No Time/Date Collected: _______________________ Comments: Collected By: *V~\ . Agency Code: _ PWS #: _ Source ID: r. ,2^Type' Descriptor: Collected From: Bill to: Location’s/lndividual’s Name Name/Company •■■■ ■ Street 3 Street City/SVZip City/St/Zip' Identification of Source Phone#: LY£Mi^Fa^:‘L^ Collection Point I CA.CH. BI? .Y '^'^";Checl^W-/e^^'^ I

BACTERIOLOGICAL ANALYSIS Lab#: Lab#: J______________________ ORGANIC POTABLE ANALYSIS ; - ORGANIC NONPOTABLE/SOLID/ANALYSIS ; t __ Heterotrophic Plate Count ■ li/^Pikg^bleHaloi^rb^ A (hemodialysis & all others) __ Trihalomethanes (524) I __ Coliform P/A (Public supplies) __ Volatile Halocarbons (524) >L--.'F^fgeableW«tic8S(e24;fe2S0)^^a^^ - __ Coliform MPN (priv well, raw, stp) __ Volatile Aromatics (524) __ Feca|,Coliforfn (all samples) __ Total Trihalomethane Potential (510) jY Organochlorine Pesticides/(608/8081) ■ __ Microscopic __ Microextractables (504) ^/PCB's'(Aroch1ore)J(6b8/gb81 __ Pesticides/PCB screen (508) _K0,t*.des(SV18«30,8151): - 'A __ Macroscopic _ API __ PCB as Decachlorobiphenyl (508Aj Other Pesticides^(^18(6630)'n<YA, _ Other:____________________ _ Herbicides (515) _^\Petroleurn Hydrocarbon Scari ' (31 oti3)Y \ __ Pesticides (525) •_ Glycols 1n^'VVater.Y/g/l^?>AY-;^;./A/<A ' Refrigerated?yes no __ Carbamate Pesticides (531) _2/Acid E^rac€ables .(625/8270)';:^t4AA •><«.; Chlorinated;?yes no __ Glyphosate (547) _■ Base Neutral .Extroctables ;(625/8276) . __ Diquat (549) ‘-•^GC/MS Unknown Scan 7 :Y/ / ;.?■ Free Chlorine Res: . mg/L __ Chlorination Disinfection Byproducts (551) Phthalates'(606MS) // i Total Chlorine Res: . mg/L _ Haloacetic Acids (552) _ Other: ■ _ Other Pesticides (SMI8/6630) pH ___________ _ UCMR List 1 ( RADIOCHEMICAL ANALYSIS _ MtBE Only (524) __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Aridity Aluminum __ Potassium , __ Turbidity __ Alkalinity ■—-Antimony : j^Seleniutrj _ pH __ Bromide Arsenic \^Silver;;;1 __ Conductivity __ Bromate/Chlorate/Chlorite ■ Barium Sodium { ■ __ Corrosivity (temp; “C) __ Chloride j^^eryllium isTThalliuml _ BOD (5 day) __ Cyanide _ Boron __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium _ Soluble BOD (5 day) __ Hardness. Total as CaCOa __ Calcium, as CaCOa __ Chemical Oxygen Demand __ Nitrogen. Ammonia as N __ Calcium. Ca*^ __ Dissolved Oxygen __ Nitrogen. Nitrate as N _ifChromium, 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 _t;<^opper __ Solids. Settleable __ Phenol '■—Iron __ Solids. Suspended __ Phosphorus Total as P _i_.Lead I£LE _TCLP-Metals .. __ Solids. Total __ Phosphorus. Ortho as P __ Magnesium _TCLP-Pesticides • ' __ Solids. Total Dissolved ' __ Sulfates ‘—Manganese _TCLP-Herblcides . __ Solids. Total Volatile __ Surfactants , -Mercury ■ *'■

_ TCLP-Volatiles __ Other: ____________ _ UV254 Molybdenum A _ TCLP-BNA’s ■ .^ickei

NYC-WTC_000072912