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

NYC 9/11 Public Portal Document

ACCo. ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM P' ster WESTCHESTER COUNTY LABORATORIES AND RESEARCH ►v.com 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): Bottle #’s: _62_U:_22_L_: ■ 1. Potable 3. Non Potable Treated 2: Non Potable 4. Other Chain of Custody? Yes No Time/Date Collected:7; /■■■ / M //K. Comments: Collected By: V , V'-.; । ' tf U 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_________ i 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) .^' GC/MS Unknown Scan ./: Free Chlorine Res:mg/L __ Chlorination Disinfection Byproducts (551) .PhthalatesT606MS) Total Chlorine Res:mg/L __ Haloacetic Acids (552) ’ r Other:____________________________ __ Other Pesticides (SMI8/6630) pH ___________ _UCMRList,1 RADIOCHEMICAL ANALYSIS _ MtBE Only (524) __ Radon __ Other_____________________

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Acidity '__ Aluminui __ Potassium __ Turbidity _ Alkalinity ; __ Antimony \ Selenium ; _ pH __ Bromide \ __ Arsenic \ ■^Silver i/'/, __ Conductivity __ Bromate/Chlorate/Chlorite \ __ Barium ’ / __ Sodium 1 ’■ ‘ / __ Corrosivity (temp:. .’C) __ Chloride ' h_.Beryllium Thallium ';^ _ BOD (5 day) __ Cyanide __^rbn _l'Vanadiurh __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium Zinc _ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOa __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*’ ZiZ” __ Dissolved Oxygen __ Nitrogen, Nitrate as N _ Metals/CN __ Chromium, Total __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Volatiles __ Chromium, Hexavalent __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N __ Semi-violatiles rLCobait __ Solids, Percent (%) __ Oil and Grease __ Pesticides/PCB's __ Copper __ Solids, Settleable __ Phenol __ Iron TCLP __ Solids, Suspended __ Phosphorus Total as P ' i- Lead - __ Solids, Total _TCLP-Metals __ Phosphorus, Ortho as P __ Magnesium __ Solids, Total Dissolved __ TCLP-Pesticides __ Sulfates .•■2_ Manganese \ __ Solids, Total Volatile __ TCLP-Herbicides __ Surfactants / __ Mercury __ Other:_________________ _ TCLP-Volatiles _ UV254 __ Molybdenum _ TCLP-BNA's V, _ Nickel

NYC-WTC_000073210