Chain of custody record, Westchester County Dept of Labs, Jan

NYC 9/11 Public Portal Document

ACCn ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ster fl )v.com WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 4 o/B o/ ■

NYS-ELAP No. 10108 Time/Date Set: Form A-70 (rev.10/01)

Sample Type (circle one): 1. Potable 3. Non Potable Treated Bottle #'s: -2/Non Potable 4. Other________ ___________ Chain of Custody? Yes No Time/Date Collected: lL Comments: Collected By:___ LI ry iJ 'X I Agency Code: PWS #:________ Source ID: Type Descriptor: Collected From: Bill to: Location's/lndividual’s Name Name/Company Street_________________ Street_________ City/St/Zip______________ City/St/Zip Identification of Source Phone#:_______ Fax#: Collection Point I CA,CH, Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:_______________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count __ Trihalomethanes (524) (hemodialysis & all others) __ Purgeable Halocarbons (624/8260) __ Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) __ 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) __ Macroscopic __ Pesticides/PCB screen (508) _ Herbicides (SMI8/6630,8151) _ API __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SM18/6630) __ 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) ■i j/ GC/MS Unknown Scan __ Diquat (549) Free Chlorine Res:mg/L __ Chlorination Disinfection Byproducts (551) _ Phthalates (606MS) 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 .i^*Aluminum __ Potassium __ Turbidity __ Alkalinity _^^ntimohy _Selenium _ pH __ Bromide 5 ✓Arsenic f Silver __ Conductivity __ Bromate/Chlorate/Chlorite .ji^arium __ Sodium __ Corrosivity (temp:. .“C) __ Chloride _!!^eryllium __ Thallium. _ BOD (5 day) __ Cyanide __ Boron _ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium _L. Zinc __ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOs __ Chemical Oxygen Demand CLP __ Nitrogen, Ammonia as N __ ^Icium, Ca*2 __ Dissolved Oxygen _k^romium, Total _ Metals/CN __ Nitrogen, Nitrate as N __ Total Organic Carbon __ Volatiles __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Semi-violatiles __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N _{r<5obalt __ Pesticides/PCB’s __ Solids, Percent (%) __ Oil and Grease _j/Copper __ Solids, Settleable __ Phenol Tpn __ Solids, Suspended __ Phosphorus Total as P __ .ead I£LE _TCLP-Metals Solids, Total __ Phosphorus, Ortho as P __ Magnesium __ TCLP-Pesticides __ Solids, Total Dissolved :__ Sulfates ^X^ahganese __ TCLP-Herbicides __ Solids, Total Volatile __ Surfactants .Li^ercury _ TCLP-Volatiles __ Other: _______ i_____ _ UV254 Molybdenum _ TCLP-BNA’s _lZf5ickel

NYC-WTC_000073121