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

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ester WESTCHESTER COUNTY LABORATORIES AND RESEARCH I pv.com 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)

SaiTiple Type (circle one): 4 j/Potable 3. Non Potable Treated Bottle #’s: 2. Non Potable 4. Other____________ Chain of Custody? Yes No Time/Date Collected: Comments: Collected By:L Agency Code: PWS #:________ Source ID: Type Descriptor: Collected From: Bill to: Location’s/lndividual's Name 032^ 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) __ Purgeable Halocarbons (624/8260) (hemodialysis & all others) __ 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) V__ Acid Extractables (625/8270) no JL Glyphosate (347) •__ Base Neutral Extractables (625/8270) Chlorinated:?yes _ Diquat (549) ' , GC/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 ___________ _UCMRList1 RADIOCHEMICAL ANALYSIS _MtBE Only (524) __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: / / __ Color __ Acidity Aluminum __ Potassium __ Turbidity __ Alkalinity Antimony __ Selenium _ pH __ Bromide Arsenic Silver __ Conductivity __ Bromate/Chlorate/Chlorite y Barium __ Sodium __ Corrosivity (temp:. °C) __ Chloride y 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 __ Nitrogen, Ammonia as N __ Calcium, Ca*’ CLE _ Metals/CN __ Dissolved Oxygen __ Nitrogen, Nitrate as N ^Chromium, 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 ' Copper __ Solids, Settleable __ Phenol _ Iron TCLP __ Solids, Suspended __ Phosphorus Total as P __ Lead _TCLP-Metals Solids, Total __ Phosphorus, Ortho as P Magnesium __ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates jL Manganese _ TCLP-Herbicides __ Solids, Total Volatile __ Surfactants Mercury _ T(3tB.Volatiles Other: ______________ _ UV254 Molybdenum _ TCLP-BNA's Nickel

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