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

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM tester jov.com 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)

Sample Type (circle one); (^^pPotable 3. Non Potable Treated Bottle #’s: A-■ / /'

2. Non Potable 4. Other_______ Chain of Custody? Yes___ No ^'Tme/Date Collected: Comments: Collected By; < • YJ,'/. Agency Code: PWS #:________ Source ID; Type Descriptor: Collected From: Bill to: ^Location's/lndividual's Name 02 2 06 Name/Company Street_____________ Street_________ City/SVZip_________ 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 __ 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 (SM 18/6630,8151) _ API __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SMI8/6630) __ 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) _il 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#: ' Aluminum __ Color __ Acidity __ Potassium __ Turbidity __ Alkalinity 2l Antimony 2:1 Selenium _ pH __ Bromide _L Arsenic H Silver __ Conductivity __ Bromate/Chlorate/Chlorite I, Barium __ Sodium __ Corrosivity (temp: ’C) __ Chloride Beryllium jtl'Thallium _ BOD (5 day) __ Cyanide __ Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium jx Zinc ; _ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOs CLP __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*^ __ Dissolved Oxygen _ Metals/CN __ Nitrogen, Nitrate as N _lfChromium, Total __ Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Semi-violatiles __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N JICobalt __ Pesticides/PCB’s __ Solids, Percent (%) __ Oil and Grease _ Copper __ Solids, Settleable __ Phenol _L Iron __ Solids, Suspended __ Phosphorus Total as P 2_ Lead TCLE _TCLP-Metals Solids, Total __ Phosphorus, Ortho as P __ Magnesium __ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates JI Manganese _TCLP-Herbicides __ Solids, Tot^ Volatile __ Surfactants J_ Mercury _ TCLP-Volatiles Other: _ UV254 L Molybdenum _ TCLP-BNA's _i_ Nickel

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