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

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM lester WESTCHESTER COUNTY LABORATORIES AND RESEARCH Tov.com 2 Dana Road, Valhalla, New,York 10595 ^/l (914)231-1620 Fax (914) 231-1772 NYS-ELAP No. 10108 Time/Date Set: fc;. ?.sxi Form A-70 (rev. 10/01)

Sample Type (circle one): _1_^Potable 3. Non Potable Treated Bottle #’s: f 1 U'A >__________

2. Non Potable 4. Other—___ t------- J---------- Chain of Custody?___ Yes No Time/Date Collected:: 4 g-6^6 Comments: Collected By: V\ < 11~ ~ ( - 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#:_______________________ • y ORGANIC POTABLE ANALYSIS ' ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Coynt (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 (SMI8/6630,8151) _ 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) ,, V __ 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 __ Acidity Juminum __ Potassium j', __ Turbidity __ Alkalinity '■‘^ntimonv vXselenium _ pH __ Bromide .^Arsenic Silver __ Conductivity __ Bromate/Chlorate/Chlorite v^Barium'; __ Sodium __ Corrosivity (temp:. .’C) __ Chloride Beryllium iifThallium _ BOD (5 day) __ Cyanide __ Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium jr^inc _ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOs __ Chemical Oxygen Demand "CLP __ Nitrogen, Ammonia as N _Galcium, Ca*^ __ Dissolved Oxygen __ Nitrogen, Nitrate as N '^Chromium, Total _ Metals/CN __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Volatiles __ Chromium, Hexavalent __ Total Organic Halides __ Semi-violatiles __ Nitrogen, Total Kjeldahl as N ^r^obalt __ Solids, Percent (%) ^.Copper __ Pesticides/PCB’s __ Oil and Grease __ Solids, Settleable __ Phenol ^Iron __ Solids, Suspended ^ead TCLP __ Phosphorus Total as P __ TCLP-Metals __ Solids, Total __ Phosphorus, Ortho as P ^Magnesium jXManganese __ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates _ Solids, Total Volatile ^Mercury _TCLP-Herbicides __ Surfactants __ UV254 ^Molybdenum _ TCLP-Volatiles Other:______ ^z4jickel _ TCLP-BNA’s

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