Chain of custody form for laboratory samples, Westchester County Lab

NYC 9/11 Public Portal Document Westchester ov.com ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914) 231-1620 Fax (914) 231-1772 Time/Date Set: Sample Type (circle one): 1. Potable 3. Non Potable Treated 2. Non Potable 4. Other Time/Date Collected: 2602 Collected By: Collected From: Location's/Individual's Name. Street City St/Zip Identification of Source Collection Point Agency Code:_ NOW& uld Blank Bottle #'s: P2630 Chain of Custody?. Yes Comments: PWS #: Source ID: Bill to: Name/Company Street City/St/Zip Phone#: CA,CH, BI? BACTERIOLOGICAL ANALYSIS Labit Heterotrophic Plate Count (hemodialysis & all others) Coliform P/A (Public supplies) Coliform MPN (priv well, raw, stp) Fecal Coliform (all samples) Microscopic Macroscopic API Other Refrigerated? Chlorinated:? yes yes Free Chiorine Rest Total Chiorine Ress mg/L mg/L pH RADIOCHEMICAL ANALYSIS Radon Other Lab# ORGANIC POTABLE ANALYSIS e Trihalomethanes (524) Volatile Halocarbons (524) Volatile Aromatics (524) Total Trihalomethane Potential (510) Microextractables (504) Pesticides/PCB screen (508) PCB as Decachlorobiphenyl (508A) Herbicides (515) Pesticides (525) Carbamate Pesticides (531) Glyphosate (547) Diquat (549) Chlorination Disinfection Byproducts (551) Haloacetic Acids (552) Other Pesticides (SM18/6630) UGMR List 1 MtBE Only (524) INORGANIC ANALYSIS REQUESTED - Lab#: Color Turbidity pH Conductivity Corresivity temp °C) BOD (5 day) Carbonaceous BOD (5 day) Soluble BOD (5 day) Chemical Oxygen Demand Dissolved Oxygen Total Organic Carbon Total Organic Halides Sollds, Percent (%) Solids, Settleable Sollds, Suspended Solids, Tota Solids, Total Dissolved Solids, Total Volatile Other Acidity Alkalinity Bromide Bromate/Chiorate/Chlorite Chloride Cyanide Fluoride Hardness, Total as CaCO3 Nitrogen, Ammonia as N Nitrogen, Nitrate as N Nitrogen, Nitrite as N Nitrogen, Total Kjeldahl as N Oll and Grease Pheno Phosphorus Total as P Phosphorus, Ortho as P Sulfates Surfactants UV254 Aluminum Antimony Arsenic Barium Beryllium Boron Cadmium Calcium, as CaCOs Calclum, Ca*2 Chromium, Total Chromium, Hexavaient Cobalt Copper fron Lead Magnesium Manganese _Mercury Molybdenum Nickel NYC-WTC_000072993 nelaci NYS-ELAP No. 10108 Form A-70 (rev. 10/01) 0201 LType Descriptor: Fax#: Check#: Amount$ ORGANIC NONPOTABLE/SOLID ANALYSIS - Purgeable Halocarbons (624/8260) Purgeable Aromatics (624/8260) Acrolein & Acrylonitrile (8260) Organochlorine Pesticides (608/8081) PCB's (Arochlors) (608/8081) Herbicides (SM18/6630,8151) Other Pesticides(SM18/6630) Petroleum Hydrocarbon Scan (310-13) Glycols in Water Acid Extractables (625/8270) Base Neutral Extractables (625/8270) GC/MS Unknown Scan Phthalates (606MS) Othert Potassium Selenium Silver Sodium Thallium Vanadium Zing CLP Metals/CN Volatiles _ Semi-violatiles Pesticides/PCB's TCLP TCLP-Metals TOLP-Pesticides TCLP-Herbicides TCLP-Volatiles: L TCLP-BNA'S DILd 126 (02 9:53am