Chain of Custody Record, Westchester County Dept of Labs

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ester Fl ov.com WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 NYS-ELAP No. 1.0108 Time/Date Set: ; y' Form A-70 (rev.10^1)

Sample Type (circle one): 1. Potable 3. Non Potable Treated Bottle 2. Non Potable 4. Other Chain of Custody?___ Yes___ No Time/Date Collected:__________________ : -- 2-1 Comments: Collected Bv: t A Q 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#: Collection Point 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) __ 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 (SM18/6630) pH ------------------- _UCMRList 1 RADIOCHEMICAL ANALYSIS _ MtBE Only (524) __ Radon __ Other____________________

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

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