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

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM aester TOvcom WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2:- 2 Dana Road, Valhalla, New York 10595 ■ ^(1 1- (914)231-1620 Fax (914) 231-1772 NYS-ELAP No. 10108 Time/Date Set: Form A-70 (rev.10/01)

Sample lype (circle one): fi. Potable’ 3. Non Potable Treated Bottle #’s: ■ <-■ ■ /<• • -j 7/'/ / Z.’ Ndn Potable 4. Other____________ Chain of Custody?___ Yes___ No Time/Date Collected: /7 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 (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 (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) 'GO/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 v' RADIOCHEMICAL ANALYSIS _ MtBE Only (524) __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#; __ Color __ Acidity ^-iZSTAIuminum __ Potassium 7 / __ Turbidity __ Alkalinity / __ Antimony ' -_ZSelehiurh _ pH __ Bromide / __ Arsenic j < _Silver J' __ Conductivity __ Bromate/Chlorate/Chlorite; __ Barium / ■_2;-Sodium-' __ Corrosivity (temp: .“C) __ Chloride BerylliuDJ---^ - - - - Thallium _ BOD (5 day) __ Cyanide 12‘Boron ‘.xVanadium- __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Soluble BOD (5 day) __ Hardness, Total as CaCOs I __ Calcium, as CaCOs __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*^ [CLP--- __ Dissolved Oxygen __ Nitrogen, Nitrate as N _ Metals/CN __ Chromium, Total __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Volatiles _^.Cti£omium, Hexavalent __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N^'"___ Cobail’x __ Semi-violatiles __ Solids, Percent (%) __ Oil and Grease / ___ Copper X __ Pesticides/PCB’s __ Solids, Settleable __ Phenol i __ Iron J __ Solids, Suspended __ Phosphorus Total as P . _ Lead_^ - TCLP __ Solids, Total __ Phosphorus, Ortho as P _TCLP-Metals Magnesium __ Solids, Total Dissolved __ Sulfates __ TCLP-Pesticides -■1_ Manganese "-x __ Solids, Total Volatile __ Surfactants _TCLP-Herbicides __ Mercury j __ Other:_________________ _ UV254 _ TCLP-Volatiles __ Molybdenum / _ TCLP-BNA's . __ Nickel

NYC-WTC_000073209