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

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM tester WESTCHESTER COUNTY LABORATORIES AND RESEARCH yov.com is*-" 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): (T. Pota^ 3. Non Potable Treated Bottle #’s: ; V ■ ■

2? Ndn Potable 4. Other____________ Chain of Custody?___ Yes___ No Time/Date Collected: ___ On ?• Comments: Collected By: Agency Code: PWS #:______ Source ID: Type Descriptor: Collected From: Bill to: Location’s/lndividual's Name Name/Company Street_____________ Street________ City/SVZip_________ 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 (SM18/6630,8151) _ 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) _ 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 ___________ __ UCMR Listi RADIOCHEMICAL ANALYSIS __ MtBE Only (524) __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color _ A:idity _ 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 I-' __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium _ Zinc •• _ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOa ■CLE “ __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*^ __ Dissolved Oxygen _ Metals/CN __ Nitrogen, Nitrate as N __ Chromium, Total __ Total Organic Carbon _ Volatiles __ 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 __ Solids, Suspended __ Phosphorus Total as P ICJLE — Lead _TCLP-Metals » Solids, Total __ 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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