Chain of custody record with sampling and analysis fields

NYC 9/11 Public Portal Document % apes ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM oon Sop ss 4 ester WESTCHESTER COUNTY LABORATORIES AND RESEARCH i et 2 Dana Road, Valhalla, New York 10595 ‘ (914) 231-1620 Fax (914) 231-1772 — NYS-ELAP No. 10108 Time/Date Set: Form A-70 (rev.10/01) , Sample Type (circle one): P P ~ 4g of! . & - “yy < (1, Potable 3. Non Potable Treated Bottle #'s: 2600), OL6O, 2 LOL, a Yl sy [42 é. 2. Non Potable 4, Other _ Chain of Custody? ____ Yes ___ No ; Le Time/Date Collected: ASS/ Ser: 4 LU Darn Comments: *._*." : Collected By: _¢:.+ Ger: 2S ae Agency Code: a PWS #: Se Source 1D:____” Type Descriptor: 5 “AY ate Collected From: “ ea ied + Bill to: . fe oo “ Location’ s/individual’s Name f) a 72 : Name/Company at Street Te Street We City/SUZip ‘ : City/St/Zip = : identifi cation of ae , fac Phone#: Fax#: a a. G ae . in . NYS MOU Bes Collection Point u Ast awl rt ree ona — CA,CH, BI? Amount BACTERIOLOGICAL"ANALYSIS « “i # — ste “. ad ep “ 4 ed ny as Lab#: _~ Heterotrophic’ ‘Plate Count (hemodialysis &' all’ others) ___ Coliform P/A (Public supplies) . _— Coliform MPN (priv well, raw, stp)” __ Fecal Coliform (all samples) “__ Trihalomethanés (524) . ». — Votatigtaromatig 4(524) > _ Pesti¢idés (525) ‘ORGANIC’ POTABLE ANALYSIS. _ Volatile'Halocarbons* (524) _ Total Trinalomethane Potential (510) ois ___ Microscopic - -. Migroextractables (504) Macroscopic . “gy _ Pesticides/PCB screen (508). pe \-) ee eee ed can ‘* PCE as ‘Decachiorobiphenyl (508A) ° 7 peo Wf —Herkicides (515 ___ Other: a ; rhici (515) ORGANIC NONPOTABLE/ SOLID, ‘ANALYSIS - St Purgeable Halocarboris (624/8260) | Purgéable Aromatics (624/8260) ° -“Acrolein & Acrylonitrile (8260): ? = Orgariochlorine Pesticides “(608/8081) : PCB's (Arochlors) '(608/8081) : Herbicides (SM18/6630, 8151) _ Other’ Pesticides (SMi8/6630) © Petroleum Hydrocarbon Scan (310-13) __ Glycols in Water’ 2 --, — Acid Extractables (625/8270) Refrigerated? yes ____ no __ Carbamate Pesticides (531) Chlorinated: i -_ yes ____ no, — Glyphosate (547) ; Base Neutral Extractables (625/8270)*: Te as ~_Diquat’ (549) Pa 7 GciMs Unknown Scan Free Chlorine Res: ~ mg/L. __ Chlorination Disinfectiog Byproducts (551) __ Phthalates (606MS) Total Chlorine Reé: : mg/L ___Haloacetic Acids (552)? ° _ ' Other: pH a __ Other Pesticides (SM18/6630) BOO we __.. ___UCMR List 1 7 : RADIOCHEMICAL ANALYSIS ° — MtBE Only (524) Radon ; 5 |__ Other - INORGANIC ANALYSIS REQUESTED - Lab#: i pc “Ail o —.. Color _ Acidity i) i oft 9) v Aluminum __. Potassium —. Turbidity _— Alkalinity vv _~ Antimony _VSelenium __ pH __. Bromide Arsenic i Silver. : ___ Conductivity *__ Bromate/Chlorate/Chlorite # Barium _. Sodium ; vom —.. Corrosivity (temp: °C) _— Chloride a. Beryllium veal. Thallium =. ___ BOD (5 day) ~~ Cyanide _~ Boron coe __Yanadium ___ Carbonaceous BOD (5 day) uz Fluoride ¢. __ Cadmium ty Zinc __ Soluble BOD (5 day) .. Hardness, Total as CaCO3 —— Calcium, as CacOs Ss cL __. Chemical Oxygen Demand _— Nitrogen, Ammonia as N Calcium, Cat? : CN __. Dissolved Oxygen _~ Nitrogen, Nitrate as N “VChromium, Total “~~ SPE — Vata — Total Organic ¢ Carbon... —_— Nitrogen, Nitrite as N’ _— Chromium, Hexavalent’. —_ Semi. es latil — Total Organic’ "Halides’ __ Nitrogen, Total Kjeldah! as -N V Cobalt * * —_ Pesticide SPCI __ Solids, Percent (%) __ Oil and Grease om Copper “i. ~: —— Pesticides/PCB’s __. Solids, Settleable © __. Phenol “ Iron, . | ToLp _— Solids, Suspended __ Phosphorus Total as P “Wiead =. oa TCLP-M S& Solids, Total Mths. . __. Phosphorus, Ortho as P __ Magnesium Son — rep metals — Solids, Total Dissolved 4 _ Sulfates ~ v 7 Mangatee pkey TCLP-Herbien 1, Solids, Total Jolatilge” mn . _ Surfactants ™ — “Herbicides Other: ped | . — TCLP-Volatiles 7, Ty —_— oa! __. TCLP-BNA‘s i ae ee Be NYC-WTC_000072937