Chain of Custody Record, Westchester County Dept of Labs

NYC 9/11 Public Portal Document • • —T an.

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ester Tov.com WESTCHESTER COUNTY LABORATORIES AND RESEARCH * '* I

2 Dana Road, Valhalla, New York 10595 uZ ■ I (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 ■' 1 Time/Date Collected: Comments: Collected By: Agency Code: ?v U • CX. 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) X. 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 __ Aluminum __ Potassium __ 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 __ Zinc _ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOa __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca+2 GLE __ Dissolved Oxygen _ Metals/CN __ Nitrogen, Nitrate as N __ Chromium, Total __ Total Organic Carbon __ Volatiles __ 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 TCLP __ Phosphorus Total as P __ Lead __ Solids, Total _TCLP-Metals __ Phosphorus, Ortho as P __ Magnesium __ ; Solids, Total Dissolved __ TCLP-Pesticides __ Sulfates __ Manganese __ Solids, Total Volatile _TCLP-Herbicides __ Surfactants __ Mercury __ Other:_________________ _ TCLP-Volatiles _ UV254 __ Molybdenum TCLP-BNA's _ Nickel

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