Westchester County Lab chain of custody form

NYC 9/11 Public Portal Document Westchester ov.com ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York . 10595 (914) 231-1620 Fax (914) 231-1772 Time/Date Set: Sample Type (circle one): 1.Potable 3. Non Potable Treated 2. Non Potable 4. Other Time/Date Collected: Collected By: 21 Agency Code: Collected From: Location's/Individual's Name 03391 Street City/St/Zip Identification of Source Collection Point Bottle #s: 2c Chain of Custody? Comments: PWS #: Bill to: Name/Company Street City/St/Zip Phone#: CA,CH, BI? es_ No Source ID: BACTERIOLOGICAL ANALYSIS Lab#: Labati Heterotrophic Plate Count (hemodialysis & all others) Coliform PIA (Public supplies) Coliform MPN (priv well, raw, stp) Fecal Coliform (all samples) Microscopic Macroscopic APL Othera Refrigerated? Nyes Chiorinated:? Free Chlorine Res: Total Chlorine Ress amg/L mg/L PH ORGANIC POTABLE ANALYSIS Trihalomethanes (524) Volatile Halocarbons (524) Volatile Aromatics (524) Total Trhalomethane Potential (510) Microextractables (504) Pesticides/PCB screen (508) PCB as Decachlorobiphenyl (508A) Herbicides (515) Pesticides (525) Carbamate Pesticides (531) Glyphosate (547) Diquat (549) Chiorination Disinfection Byproducts (551) Haloacetic Acids (552) Other Pesticides (SM18/6630) UCMR List 1 RADIOCHEMICAL ANALYSIS MIBE Only (524) Radon Other INORGANIC ANALYSIS REQUESTED - Lab#: color Turbidity pH Conductivity Corrosivity (temp BOD (5 day) Carbonaceous BOD (5 day) Soluble BOD (5 day) Chemical Oxygen Demand Dissolved Oxygen Total Organic Carbon Total Organic Halides Solids, Percent (%) Solids, Settleable Sollds, Suspended Solids, Total Len Solids: Total Dissolved Solco Total Volatile Otners Acidity Alkalinity Bromide Bromate/Chlorate/Chlorite Chloride Cyanide Fluoride Hardness, Total as CaCO3 Nitrogen, Ammonia as N Nitrogen, Nitrate as N Nitrogen, Nitrite as N Nitrogen, Total Kjeldahl as N Oll and Grease Phenol Phosphorus Total as P Phosphorus, Ortho as P Sulfates Surfactants UV254 158 Aluminum Antimony LArsenic Barium Berylium Boron Cadmium Calcium, as CaCOs Calcium, Ca*2 <Chromium, Total _ Chromium, Hexavalent Cobalt Copper ron ILead Magnesium Manganese Mercury _Molybdenum Nickel NYC-WTC_000073186 nelc: NYS-ELAP No. 10108 Form A-70 (rev.10/01) Type Descriptor: Fax#: Check#: Amounts ORGANIC NONPOTABLE/SOLID ANALYSIS Purgeable Halocarbons (624/8260) Purgeable Aromatics (624/8260) Acrolein & Acrylonitrile (8260) Organochlorine Pesticides (608/8081) PCB's (Arochlors) (608/8081) Herbicides (SM18/6630,8151) Other Pesticides (SM18/6630) Petroleum Hydrocarbon Scan (310-13) Glycols in Water Acid Extractables(625/8270) Base Neutral Extractables (625/8270) GC/MS Unknown Scan Phthalates (606MS) Other Potassium Selenium Silver Sodium Thailium Vanadium Zing CLP Metals/CN Volatiles Semi-violatiles Pesticides/PCB's ICLP TCLP-Metals LTCLP-Pesticides TCLP-Herbicides TCLP-Volatiles TCLP-BNAS