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

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM tester nov.com WESTCHESTER COUNTY LABORATORIES AND RESEARCH ■ A* 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): 1. Potable 3. Non Potable Treated Bottle #’s: 2. Non Potable 4. Other ^^J^^^^j^Chain of Custody?___ Yes___ No Time/Date Collected: Comments: Collected By: _2__2 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_______ 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 (SMI 8/6630,8151) _ API __ PCB as DecachlorobipUftnyl (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) JI Diquat (549) * Ji; GC/MS Unknown Scan Free Chlorine Res: . mg/L __ Chlorination Disinfectioo-Byproducts (551) _ Phthalates (606MS) Total Chlorine Res: . mg/L __ Haloacetic Acids (552) _ Other:____________________________ _ Other Pesticides (SMI8/6630) pH ________ _UCMRList 1 RADIOCHEMICAL ANALYSIS / sJi MtBE Only.(524):;J,::-- __ Radon __ Other_________________ _____

INORGANIC ANALYSIS REQUESTED - Lab#; jjkZ- __ Color _ Acidity JL Aluminum __ Potassium __ Turbidity __ Alkalinity »- Antimony J_ Selenium _ pH __ Bromide Arsenic Silver __ Conductivity __ Bromate/Chlorate/Chlorite Barium __ Sodium, __ Corrosivity (temp: .’C) __ Chloride Beryllium jiT Thallium _ BOD (5 day) __ Cyanide __ Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium ■ Zinc __ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOs __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N CLP ___ Calcium, Ca*^ __ Dissolved Oxygen __ Nitrogen, Nitrate as N _ Metals/CN SjChromium, Total __ Total Organic Carbon .. __ Nitrogen, Nitrite as N""--- __ Volatiles . __ Chromium, Hexavalent __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N __ Semi-violatiles Cobalt __ Solids, Percent (%) __ Oil and Grease __ Pesticides/PCB’s .2=1 Copper __ Solids, Settleable __ Phenol Iron __ Solids, Suspended __ Phosphorus Total as P _^-Lead ICLE • Solids, Total _TCLP-Metals __ Phosphorus, Ortho as P __ Magnesium __ Solids, Total Dissolved __ TCLP-Pesticides __ Sulfates _v.-Manganese __ Solids, Total Volatile __ TCLP-Herbicides __ Surfactants Mercury __ Other: ___________ _ UV254 _ TCLP-Volatiles Molybdenum _ TCLP-BNA's isi Nickel

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