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

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ester pvcom 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 (rev. 10/01) /J Sample Type (circle one): '■ipptebteJ 3. Non Potable Treated Bottle #’s: 2. Non Potable 4. Other____________ Chain of Custody? Yes___ No Time/Date Collected: 1___ 2. Comments: Collected By:___________ 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 (hemodialysis & all others) __ Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) __ Coliform P/A (Public supplies) __ Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ 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 (SM18/6630,8151) _ API __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SMI 8/6630) __ 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) _ Diquat (549) i^f^C/MS Unknown Scan 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 ___________ _UCMR List 1 RADIOCHEMICAL ANALYSIS _ MtBE Only (524) __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#; __ Color _ Aridity ^Aluminum __ Potassium __ Turbidity __ Alkalinity _ Antimony Selenium _ pH __ Bromide _ Arsenic _ Silver __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium . __ Corrosivity (temp;. °C) __ Chloride __ Beryllium __ Thallium • _ BOD (5 day) __ Cyanide __ Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium Zinc _ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOs __ Chemical Oxygen Demand CLP __ Nitrogen, Ammonia as N __ Calcium, Ca*^ __ Dissolved Oxygen __ Nitrogen, Nitrate as N .^Chromium, Total _ Metals/CN __ Total Organic Carbon __ Volatiles __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Total Organic Halides __ Semi-violatiles __ Nitrogen, Total Kjeldahl as N jL Cobalt __ Solids, Percent (%) __ Pesticides/PCB’s __ Oil and Grease __ Copper __ Solids, Settleable __ Phenol __ ' Iron __ Solids, Suspended __ Phosphorus Total as P " Lead TCLP Solids, Total _TCLP-Metals __ Phosphorus, Ortho as P __ Magnesium __ Solids, Total Dissolved __ TCLP-Pesticides __ Sulfates __ Manganese __ Solids, Total Volatile __ TCLP-Herbicides __ Surfactants __ Mercury Other:_________ :________ _ TCLP-Volatiles _ UV254 __ Molybdenum _ TCLP-BNA’s __ Nickel

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