Chain of Custody Record, Westchester County Dept of Labs

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ester WESTCHESTER COUNTY LABORATORIES AND RESEARCH pv.com o ■ 2 Dana Road, Valhalla, Nev/York 10595 o ' (914) 231-1620 Fax (914) 231-1772 i /' NYS-ELAP No. 10108 Time/Date Set: / Form A-70 (rev. 10/01)

Sample Type (circle one): Bottle #’s^^^ '"V ' - < - r J. 1. Potable 3. Non Potable Treated 2. Non Potable 4. Other____________ Chain of Custody? Yes No Time/Date Collected: Comments: Collected By:___ _L 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 CA.CH, Bl? Check#: Amounts

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:_______________________ dfebANlC NONPOTABLE/SOLID ANALYSIS ORGANIC POTABLE ANALYSIS __ Heterotrophic Plate Count __ Trihalomethanes (524) _£-' Purgeable Halocarbons (624/8260) (hemodialysis & all others) __ 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) ^I' Herbicides (SM18/6630,8151) _ API __ PCB as Decachlorobiphenyl (508A) Other Pesticides (SMI8/6630) __ Other:_____________________ __ Herbicides (515) _i2:'Petroleum Hydrocarbon Scan (310-13) __ Pesticides (525) <2£i?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) " 2s' 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 __ Acidity __ ^-Aluminum __ Potassium __ Turbidity __ Alkalinity Antimony y; _ Selenium _ pH __ Bromide _ Arsenic __ Silver __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium __ Corrosivity (temp:. °C) __ Chloride j^Beryllium __ Thallium _ BOD (5 day) __ Cyanide __ Boron __ Vanadium •__ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium _1_ Zinc __ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOs CLP __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*^ > , _ Metals/CN __ Dissolved Oxygen __ Nitrogen, Nitrate as N __Chromium, Total __ Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Semi-violatiles __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N _ Cobalt __ Pesticides/PCB’s __ Solids, Percent (%) __ Oil and Grease __ Copper __ Solids, Settleable __ Phenol ■ Iron TCLP __ Solids, Suspended __ Phosphorus Total as P __ Lead _TCLP-Metals __ Solids, Total __ Phosphorus, Ortho as P __ Magnesium __ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates __ Manganese __ TCLP-Herbicides __ Solids, Total Volatile __ Surfactants __ Mercury _ TCLP-Volatiles _ Other:_____ s___________ _ UV254 j_ Molybdenum _ TCLP-BNA's _ Nickel

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