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

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ster WESTCHESTER COUNTY LABORATORIES AND RESEARCH iv.com 2 Dana Road, Valhalla, New York 10595 II \ (914)231-1620 Fax (914) 231-1772 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: 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/St/Zip _________ City/St/Zip Identification of Source Phone#:_______ Fax#: > = • 1 ' Collection Point I CA,CH, Bl? 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) __ Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) __ Coliform MPN (priv w/ell, 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) _ Bdse Neutral Extractables . (625/8270) __ Diquat (549) ji^:^^C/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 List1 RADIOCHEMICAL ANALYSIS _ MtBE Only (524) __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color ;_ Aridity ii. Aluminum __ Potassium , __ Turbidity __ Alkalinity __ Antimony Selenium. _ pH __ Bromide __ Arsenic ’>^ilver __ Conductivity __ Bromate/Chlorate/Chlorite _ Barium __ Sodium __ Corrosivity (temp:. .’C) __ Chloride _ Beryllium j,x'Thallium . __ BOD (5 day) __ Cyanide __ Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride •__ Cadmium V^Zinc _ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOa CLP ____ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*^ __ Dissolved Oxygen __ Nitrogen, Nitrate as N __ Metals/CN •__ Chromium, Total __ Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Total Organic Halides __ Semi-violatiles __ Nitrogen, Total Kjeldahl as N _ Cobalt __ Solids, Percent (%) __ Pesticides/PCB's __ Oil and Grease __ Copper __ Solids, Settleable __ Phenol . Iron __ Solids, Suspended __ Phosphorus Total as P __ Lead IfiLLE __ Solids, Total _TCLP-Metals __ Phosphorus, Ortho as P __ Magnesium . __ Solids, Total Dissolved __ TCLP-Pesticides __ Sulfates __ Manganese __ TCLP-Herbicides __ Solids, Total Volatile __ Surfactants __ Mercury __ Other: __ _______________ _ TCLP-Volatiles _ UV254 __ Molybdenum _ TCLP-BNA’s __ Nickel

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