Chain of Custody Record, Westchester County Dept of Labs

NYC 9/11 Public Portal Document I . I I ■)

A CC0

.Westchester i ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND, RESEARCH 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 b" I sAatJ X / NYS-ELAP No. 10108 Time/Date Set: Form A-70 (rev. 10/01)' r ■

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' 1 .Potable 3. Non Potable Treated Bottle #’s: .•/■Az 2.'Non Potable 4. Other___________ Chain of Custody? Yes___ No Al Time/Date Collected: Collected By: Agency Code: Comments: PWS #:________ Source ID: Type Descriptor? I .d Collected From: Bill to: Location’s/lndividual's Name Name/Company _ I. Street_________________ Street_________ ! } City/St/Zip______________ City/St/Zip’ Identification of Source Phone#:_______ Fax#: Collection Point, . - CA,CH, Bl? Check’#: Amounts I ¥ BACTERIOLOGICAL ANALYSIS Lab#: Lab#:_______________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS^ __ Heterotrophic Plate Count (hemodialysis & all others) __ Trihalomethanes (524) _1 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) Ji Acrolein & Acrylonitrile (8260) __ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081) - __ Microscopic __ Microextractables (504) . PCB's (Arochlors) (608/8081) _i Herbicides (SMI8/6630,8151) 1 __ Macroscopic __ Pesticides/PCB screen (508) _ API __ PCB as Decachlorobiphenyl (508A) _ 1 .Other Pesticides (SM18/6630) ’ __ Other:_____________________ __ Herbicides (515) _L. Petroleum Hydrocarbon Scan (310-13) ■t __ Pesticides (525) __ Glycols in Water Refrigerated?yes___ no __ Carbamate Pesticides (531) _£ Acid Extractables (625/8270) Chlorinated:? yes___ no __ Glyphosate (547) _J Base Neutral Extractables (625/8270) t __ Diquat (549) __ GC/MS Unknown Scan Free Chlorine Res:mg/L __ Chlorination Disinfection Byproducts (551) Phthalates (606MS) ■I, I Total Chlorine Res: mg/L __ Haloacetic Acids (552) Other:___________________________ __ Other Pesticides (SMI8/6630) pH _UCMR List 1 RADIOCHEMICAL ANALYSIS _MtBEOnly (524) A __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: TH.' ■' •f __ Color __ Acidity __ Aluminum __ Potassium __ Turbidity __ Alkalinity __ Antimony __ Selenium _ pH __ 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 p _ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOa CLP __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*^ _ Metals/CN __ Dissolved Oxygen __ Nitrogen, Nitrate as N __ Chromium, Total r __ Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent I __ total Organic Halides __ Semi-violatiles __ Nitrogen, Total Kjeldahl as N __ Cobalt __ Pesticides/PCB’s 4 __ Solids, Percent (%) __ Oil and Grease __ Copper __ Solids, Settleable __ Phenol __ Iron f TCLP __ Solids, Suspended __ Phosphorus Total as P __ Lead __ TCLP-Metais _ _ Solids, Total __ Phosphorus, Ortho as P __ Magnesium __ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates __ Manganese __ TCLP-Herbicides __ Solids, Total Volatile __ Surfactants __ Mercury _ TCLP-Volatiles __ Other:_________________ _ UV254 __ Molybdenum _ TCLP-BNA’s ■*>

t _ __________ I __ Nickel

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