Chain of Custody Record, Westchester County Dept of Labs

NYC 9/11 Public Portal Document I

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

Sample Type (circle one); Y ' 1. Potable 2. Non Potable 3. Non Potable Treated 4. Other Bottle #’s: - ■ " '' Chain of Custody?___ Yes ' - - No 'I f Time/Date Collected: _________ Comments: Collected By: V 4 1 Agency Code; PWS #:______ Source ID: Type Descriptor: Collected From: Bill to: ■ T- Location’s/lndividual’s Name Street__________________ I City/St/Zip_______________ Name/Company Street_______ City/St/Zip I■TA

Identification of Source Phone#: Fax#; I Collection Point

BACTERIOLOGICAL ANALYSIS Lab#: CA,CH, Bl? Check#: Amounts I Lab#:_______________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count (hemodialysis & all others) __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) __ Trihalomethanes (524) __ Volatile Halocarbons (524) __ Volatile Aromatics (524) __ Purgeable Halocarbons (624/8260) __ Purgeable Aromatics (624/8260) __ Acrolein & Acrylonitrile (8260) 1 __ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081) s’ __ Microextractables (504) _ PCB’s (Arochlors) (608/8081) __ Microscopic __ Pesticides/PCB screen (508) _ Herbicides (SM18/6630,8151) r __ Macroscopic _ ’API __ Other:_____________________ __ PCB as Decachlorobiphenyl (508A) __ Herbicides (515) __ Other Pesticides (SM18/6630) __ Petroleum Hydrocarbon Scan (310-13) J 1 1 I __ Pesticides (525) __ Glycols in Water Refrigerated?yes___ no __ Carbamate Pesticides (531) __ Glyphosate (547) __ . Acid Extractables (625/8270) __ Base Neutral Extractables (625/8270) :d I Chlorinated:? yes___ no Free Chlorine Res:mg/L __ Diquat (549) GC/MS Unknown Scan I' 1 I __ Chlorination Disinfection Byproducts (551) __ Phthalates (606MS) Total Chlorine Res:mg/L __ Haloacetic Acids (552) __ Other:__________________________ •r- pH*.___________ '__ Other Pesticides (SMI 8/6630) __ UCMR List 1 ■t ■■8 _ MtBE Only (524)

I RADIOCHEMICAL ANALYSIS __ Radon __ Other____________________ / a INORGANIC ANALYSIS REQUESTED - Lab#: __ iColor __ /Acidity -“S—' _ [ Aluminum __ Potassium 4 __ Turbidity __ Alkalinity __ Antimony __ Selenium __ 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 ; ’• 1 __ Soluble BOD (5 day) __ ’Chemical Oxygen Demand __ Hardness, Total as CaCOs __ Nitrogen, Ammonia as N __ Calcium, as CaCOs __ Calcium, Ca-^2 CLP ■I,. I __ Dissolved Oxygen _ Metals/CN __ 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 __ Solids, Percent (%) __ Pesticides/PCB’s __ ‘Oil and Grease __ Copper __ -Solids, Settleable __ Phenol __ Iron ■I ICLP __ Solids, Suspended __ Phosphorus Total as P __ Lead _TCLP-Metals __ Solids, Total __ 'Solids, Total Dissolved __ Phosphorus, Ortho as P __ Magnesium __ TCLP-Pesticides i _ Sulfates __ Manganese __ Solids, Total Volatile __ TCLP-Herbicides __ Surfactants __ Mercury _ TCLP-Volatiles •' other: UV254 __ Molybdenum __ TCLP-BNA’s _ Nickel 1). NYC-WTC_000073383