Chain of Custody Record, Westchester County Dept of Labs

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM tester WESTCHESTER COUNTY LABORATORIES AND RESEARCH nov.com 2 Dana Road, Valhalla, New York 10595 1-' (914)231-1620 Fax (914) 231-1772 NYS-ELAP No. 10108 Time/Date Set: Form A-70 (rev.10/01)

Sample Type (circle one): V 1, Potable 3. Non Potable Treated Bottle #’s: 2. Non Potable 4. Other Chain of Custody?___ Yes____No Time/Date Collected:_______ 2__________ Comments: Collected By: i /Y>-- • 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 __ Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) (hemodialysis & all others) __ Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) __ 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 (SMI8/6630,8151) _ API __ PCB as Decachlorobiphenyl (508A) ' Other Pesticides (SM18/6630) __ 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) i-Y'3C/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 ___________ _UCMRList 1 RADIOCHEMICAL ANALYSIS MtBE Only (524) __ Radon __ Other____________________ / / / /. ---- INORGANIC ANALYSIS REQUESTED - Lab#: / J ■ __ Color __ /Acidity ^Aluminum S _ Potassium r, . •

__ Turbidity __ Alkalinity z‘Antimony . __ ^Selenium ,T: i ; .. _ pH __ Bromide Arsenic iV^ilver __ Conductivity __ Bromate/Chlorate/Chlorite z 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 CaCOs __ Calcium, as.CaCOa . __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium. Ca*^ x. <‘,-f-. eLE __ Dissolved Oxygen ^’Chromium, Total _ Metals/CN __ Nitrogen, Nitrate as N __ Total Organic Carbon __ Volatiles __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Total Organic Halides __ Semi-violatiles __ Nitrogen, Total Kjeldahl as N z' Cobalt __ Solids, Percent (%) __ Pesticides/PCB’s __ Oil and Grease Copper __ Solids, Settleable __ Phenol _i. 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 __ Solids, Total Volatile __ TCLP-Herbicides __ Surfactants __ Mercury ■f. • TCl^P-Volatiles •/ •• Other: ____________ _ UV254 __ Molybdenum z^TCLP-BNAs.^tV.'/ _ Nickel - Sf

NYC-WTC_d00073309