Chain of Custody Record, Westchester County Dept of Labs

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ster >v.com WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 O/ ■ \ -« < * ■ "TiwTBilii^U ' X (914)231-1620 Fax (914) 231-1772 NYS-ELAP No. 10108 Time/Date Set: Form A-70 (rev.10/01)

Sample Type (circle one): Bottle #'s.^' A 1. Potable 3. Non Potable Treated 2. Non Potable 4. Other Chain of Custody? Yes___ No Time/Date Collected:___________ ;______ Comments: Collected Bv:*^J" t Agency Code: PWS #:________ Source ID: Type Descriptor: Collected From: Bill to: Location's/lndividual’s Name Name/Company Street______________________________________ Street_________ City/St/Zip__________________________________ City/SVZip 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 (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) __ 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 List 1 RADIOCHEMICAL ANALYSIS _ MtBE Only (524) __ Radon __ Other_____________________

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Aridity __ Aluminum Potassium __ Turbidity __ Alkalinity Antimony ^Selenium _ pH __ Bromide Arsenic Silver I __ Conductivity __ Bromate/Chlorate/Chlorite ^■Barium Sodium i __ Corrosivity (temp:. .’C) __ Chloride ^Beryllium Thallium i _ BOD (5 day) __ Cyanide __ Boron Vanadium I __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium 2 Zinc _ Soluble BOD (5 day) __ Hardness. Total as CaCOa _L Calcium, as CaCOs __ Chemical Oxygen Demand CLP __ Nitrogen, Ammonia as N Calcium, Ca*2 __ Dissolved Oxygen _ Metals/CN __ Nitrogen, Nitrate as N Chromium. Total __ Total Organic Carbon __ Volatiles __ Nitrogen, Nitrite as N ■Chromium. Hexavalent __ Total Organic Halides ^Cobalt __ Semi-violatiles __ Nitrogen, Total Kjeldahl as N __ Solids, Percent (%) __ Pesticides/PCB's __ 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 __ Solids, Total Dissolved __ TCLP-Pesticides __ Sulfates Manganese Solids, Total Volatile __ TCLP-Herbicides __ Surfactants Mercury V Other: __________ i Molybdenum __ TCLP-Volatiles _ UV254 _ TCLP-BNA's Nickel

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