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

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM tester WESTCHESTER COUNTY LABORATORIES AND RESEARCH ^vcom 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); 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/lndividuai's Name Name/Company _ Street____________________ Street_________ City/St/Zip_________________ City/St/Zip Identification of Source Phone#;_______ Fax#: Collection Point______ ' ■ I CA,CH. Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:_________ ______________ T 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 (SMI 8/6630) __ 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) _urCC/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 -'Aluminum __ Potassium/ Z’ > __ Turbidity _ Alkalinity Antimony Selenium ' _ pH __ Bromide Arsenic - Silver ; __ Conductivity __ Bromate/Chlorate/Chlorite Barium __ Sodium __ Corrosivity (temp:. .’C) __ Chloride _ Beryllium Thallium _ BOD (5 day) __ Cyanide __ Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium _u_ Zinc _ Soluble BOD (5 day) __ Hardness. Total as CaCOa __ Calcium, as CaCOs “CLP __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*^ __ Dissolved Oxygen __ Nitrogen, Nitrate as N _ Metals/CN _LChromium, Total __ Total Organic Carbon __ Volatiles __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Total Organic Halides __ Semi-violatiles __ Nitrogen, Total Kjeldahl as N ‘ Cobalt __ Pesticides/PCB’s __ Solids, Percent (%) __ Oil and Grease Copper __ Solids, Settleable __ Phenol __ Iron __ Solids, Suspended __ Phosphorus Total as P __ Lead TCLP _TCLP-Metals __ Solids, Total __ Phosphorus, Ortho as P __ Magnesium _ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates ■Manganese _TCLP-Herbicides __ Solids, Total Volatile __ Surfactants ‘■Tviercury _ TCLP-Volatiles __ Other: ______________ _ UV254 Molybdenum _ TCLP-BNA’s _!<TJickel

NYC-WtC_660073216