Chain of Custody Record, Westchester County Dept of Labs

NYC 9/11 Public Portal Document .’f- * ' ' 1 ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ,A^stchester WESTCHESTER COUNTY LABORATORIES AND RESEARCH -1 ' J# 2 Dana Road, Valhalla, New York 10595 O/ ■ I (914) 231-1620 Fax (914) 231-1772 NYS-ELAP No. 10108 - .j Time/Date Set: Form A-70 (rev.10/01) J Sample Type (circle one): ; 1. Potable 3. Non Potable Treated Bottle #’s: 2. Non Potable Time/Date Collected; 4. Other _____ Chain of Custody? Comments: Yes___ No f 5 Collected By:_______ Collected From: Agency Code: PWS #:________ Bill to: Source ID: Type Descriptor: l J Location's/lndividual’s Name Street_______ ’______ __ Name/Company _ Street_________ J r City/St/Zip______________ Identification of Source City/St/Zip Phone#:_______ Fax#; I Collection Point- I CA.CH, Bl? Check#: Amounts. 4 BACTERIOLOGICAL ANALYSIS Lab#: Lab#:___________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS ' ■s __ Heterotrophic Plate Count (hemodialysis & all others) __ Coliform P/A (Public supplies) __ Trihalomethanes (524) __ Volatile Halocarbons (524) __ Purgeable Halocarbons (624/8260) ' __ Purgeable Aromatics (624/8260) •I •t __ Coliform MPN (priv well, raw, stp) __ Volatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) ’ __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081) __ Fecal Coliform (all samples) , __ Microscopic __ Microextractables (504) _ PCB’s (Arochlors) (608/8081) .5 r J __ Macroscopic __ Pesticides/PCB screen (508) _ Herbicides (SM18/6630,8151) tV-. _ API __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SM18/6630) __ Other: _____________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) 1 1 __ 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::''GC/MS Unknown Scan Free Chlorine Res:mg/L __ Chlorination Disinfection Byproducts (551) _ Phthalates (606MS) Total Chlorine Res:mg/L pH I I __ Haloacetic Acids (552) _Other Pesticides (SMI8/6630) __ Other:__________________________ i _UCMR List 1 i

RADIOCHEMICAL ANALYSIS __ MtBE'Only (524) .4 __ Radon __ Other_______ _____________ A >> Z ■'5 INORGANIC ANALYSIS REQUESTED - Lab#: /) <7 I __ Color __ Aridity /■'

Aluminum ' __ Potassium 1 t __ Turbidity __ Alkalinity __ Antimony _j. Selenium — pH __ Bromide Arsenic ■ Silver '•w -3; __ 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 _ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOs -si __ Chemical Oxygen Demand CLP __ Nitrogen, Ammonia as N __ .Calcium, Ca+2

1 __ Dissolved Oxygen __ Metals/CN __ Nitrogen, Nitrate as N _:^Chromium, Total __ total Organic Carbon __ Volatiles •! __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Total Organic Halides __ Semi-violatiles __ Nitrogen, Total Kjeldahl as N J _ .'Cobalt __ Solids, Percent (%) __ Pesticides/PCB’s __ Oil and Grease - Copper [ _ Solids, Settleable __ Phenol _lron TCLP __ Solids, Suspended __ Phosphorus Total as P _ZLead __ Solids, Total __ Phosphorus, Ortho as P __ Magnesium __ TCLP-Metals __ TCLP-Pesticides '3 __ Solids, Total Dissolved __ Sulfates Manganese i __ Solids, Total Volatile __ Surfactants __ Mercury __ TCLP-Herbicides _ TCLP-Volatiles ,1 I _ Other: ____________ _ UV254 Molybdenum I ______________ _ TCLP-BNA’s Nickel j T

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