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

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ester pvcom t) WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana RoWValhalla, New York 10595 (914) 231-1620,^ (914) 231-1772 o ft NYS-ELAP No. 10108 Time/Date Set: Form A-70 (rev. 10/01)

Sample Type (circle one): 1. Potable 3. Non Potable Treated Bottle #’s: \ V ■■.... (...... i 2. Non Potable 4. Other____________ Chain of Custody? Yes___ No Time/Date Collected: 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 ■ tlllx CA,CH;fBI? 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) __ 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 (1508) _ Herbicides (SMI 8/6630,8151) __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SMI8/6630) _ API __ 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)......, isT GC/MS Unknown Scan Free Chlorine Res: . rng/L __ Chlorination DisinfecRoh Byproducts (551) _ Phthalates (606MS) Total Chlorine Res: . mg/L __ Haloacetic Acids (552) _ Other:____________________________ _ Other Pesticides (SMI8/6630) pH ------------------- _UCMRList1 RADIOCHEMICAL ANALYSIS _ MtBE Only (524) __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Aridity Aluminum __ Potassium ; ' / I __ Turbidity __ Alkalinity ,__ Antimony ...-Selenium- _ pH __ Bromide , Arsenic .hr Silver __ Conductivity __ Bromate/Chlorate/Chlorite V. Barium __ Sodium __ Corrosivity (temp:, .“C) __ Chloride t— Beryllium .^r^hallium _ BOD (5 day) __ Cyanide __ Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium Zinc __ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOs __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*^ CLE _ Metals/CN __ Dissolved Oxygen __ Nitrogen, Nitrate as N J-rChromium, Total __ Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Semi-violatiles __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N L_ Cobalt __ Pesticides/PCB’s __ Solids, Percent (%) __ Oil and Grease _ Copper __ Solids, Settleable __ Phenol .__ Iron TCLP __ Solids, Suspended __ Phosphorus Total as P Lead • _TCLP-Metals __ Solids, Total __ Phosphorus, Ortho as P __ Magnesium __ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates Manganese __ TCLP-Herbicides __ Solids, Total Volatile __ Surfactants f..-Mercury _ TCLP-Volatiles ■Z Other: > \________ _ UV254 ■ Molybdenum _ TCLP-BNA’s __Nickel

NYC-WTC_000073212