Chain of Custody Record, Westchester County Dept of Labs

NYC 9/11 Public Portal Document I __

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM '4 .^Lstchestei’ WESTCHESTER COUNTY LABORATORIES AND RESEARCH SY 2 Dana Road, Valhalla, New York 10595 UJ ■ I A ■ 1I (914) 231-1620 Fax (914) 231-1772. I ’ . .• / ■ NYS-ELAP No. 10108 Tirhe/Date Set:-' * Form A-70 (rev.10/01) t. Sample Type (circle one): ’ W 2 j (l. Potable" 2 3. Non Potable Treated Bottle #’s: 2'. Non Potable Time/Date Collected: 4. Other 1.:?; Chain of Custody? Comments: Yes___ No 1 ■t'.' Collected By: < . ■? • " Agency Code: PWS #:________ 2 Source ID: Type Descriptor: Collected From: . v Bill to: Location's/lndividual’s Name Name/Company _ I '2 Street Street_________ City/St/Zip City/St/Zip Identification of Source Phone#:_______ Fax#: Collection Point "'i I CA,CH, Bl? Check#: Amounts.

BACTERioLOGICAL ANALYSIS Lab#: Lab#: _ _________ • _______ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS _ Heterotrophic Plate Count __ . Purgeable Halocarbons (624/8260) ’ (hemodialysis & all others) __ Trihalomethanes (524) __ Coliform P/A (Public supplies) __ 'Coliform MPN (priv well, raw, stp) __ Volatile Halocarbons (524) __ Volatile Aromatics (524) __ Purgeable Aromatics (624/8260) _ j Acrolein & Acrylonitrile (8260) Si Fecal Coliform (all samples) __ ^'Microscopic __ [Macroscopic __ Total Trihalomethane Potential (510) __ Microextractables (504) __ Pesticides/PCB screen (508) __ Organochlorine Pesticides (608/8081) i _ PCB’s (Arochlors) (608/8081) _ Herbicides (SMI8/6630.8151) __ Other Pesticides (SMI8/6630) ' i ’ J 1 1 — API __ PCB as Decachlorobiphenyl (508A) __ Other:_____________________ __ Herbicides (515) ■ Petroleum Hydrocarbon Scan (310-13) j ' I __ Pesticides (525) _ Glycols in Water Refrigerated?yes___ no Chlorinated:? yes no __ Carbamate Pesticides (531) __ Glyphosate (547) __ Diquat (549) __ Acid Extra'ctables (625/8270) ■ Base Neutral Extractables (625/8270) f v^GC/MS Unknown Scan - rt Free Chlorine Res:mg/L __ Chlorination Disinfection Byproducts (551) _ Phthalates (606MS) Total Chlorine Res:mg/L __ Haloacetic Acids (552) Other:______________________ _ -t.

_Other Pesticides (SMI8/6630) ____________ _UCMR List 1 RADIOCHEMICAL ANALYSIS _ MtBE Only (524) __ Radon — Other______ _______________ f 1 INORGANIC ANALYSIS REQUESTED - Lab#: _ Color __ Acidity z _i.2.-‘'Aluminum __ Potassium __ Turbidity __ Alkalinity t-''Antimonv Selenium !■: J pH __ Bromide .x'Arsenic ' , 22Silver __Conductivity __ Brorhate/Chlorate/Chlorite Barium __ Sodium __. Corrosivity (temp:. °C) __ Chloride Beryllium ^'Thallium _ BOD (5 day) __ Cyanide ■•4 __ Boron __ Vanadium _ ; Carbonaceous BOD (5 day) __ Fluoride __ Cadmium L _ ;■ Zinc _■ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOa CLP __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*2 _ Dissolved Oxygen _ Metals/CN __ Nitrogen, Nitrate as N _:.Chromium, Total __ Volatiles __ .' Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Semi-violatiles p •4 __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N Cobalt __ Pesticides/PCB’s __Solids, Percent (%) __ Oil and Grease _£"Copper __,1 Solids, Settleable __ Phenol _ f Iron ICLP _ 1 Solids, Suspended __ Phosphorus Total as P Lead i _TCLP-Metals __ .' Solids, Total __ Phosphorus, Ortho as P __ Magnesium __ TCLP-Pesticides '•J __ ■ Solids, Total Dissolved __ Sulfates _ Manganese __ TCLP-Herbicides __ .1. Solids, Total Volatile __ Surfactants Mercury _ TCLP-Volatiles -4 Other:_____ '3__________ _ UV254 Molybdenum .1 a _ TCLP-BNA’s 1 --------------------------------- 2/ Nickel _____________ NYC-WTC_000073386