Chain of Custody Record, Westchester County Dept of Labs

NYC 9/11 Public Portal Document I

i>» ACCn ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH 'I 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 I NYS-ELAP No. 10108. Time/Date Set: ' Form A-70 (rev. 10/01 ) r Sample Type (circle one): J 1. Potable 3. Non Potable Treated Bottle #’s: e.. ■/■■•

3 2. Non Potable Time/Date Collected: Collected By: _2_ 4. Other______ _____

Agency Code: Chain of Custody? Comments; PWS #:________ Yes___ No '

Source ID; Type Descriptor; y- I1 Collected From: Bill to: Location’s/lndividual’s Name Name/Company

J Street_______ ;_________ Street_________ City/St/Zip______________ City/St/Zip * ?

Identification of Source Phone#:_______ Fax#: Collection Point rCA,CH, Bl? Check#: Amounts. I BACTERIOLOGICAL ANALYSIS Lab#: Lab#:__________________ __ ORGANIC NONPOTABLE/SOLID ANALYSIS ? ? ORGANIC POTABLE ANALYSIS __ Heterotrophic Plate Count a (hemodialysis & all others) __ Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) __ Coliform P/A (Public supplies) _ Volatile Halocarbons (524) __ Volatile Aromatics (524) ■■ Purgeable Aromatics (624/8260) __ Acrolein & Acrylonitrile (8260) ¥ ■fl __ Coliform MPN (priv well, raw, stp) __ Fecal Coliform (all samples) __ Microscopic __ Total Trihalomethane Potential (510) __ Microextractables (504) __ Organochlorine Pesticides (608/8081) ' ? _ PCB’s (Arochlors) (608/8081) ■y fl __ Macroscopic _ API __ Pesticides/PCB screen (508) __ PCB as Decachlorobiphenyl (508A) _ Herbicides (SMI 8/6630,8151) ’ __ Other Pesticides (SMI8/6630) '5 1 3 __ Other:_____________________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-,13) . i __ Pesticides (525) __ Glycols in Water _J Acid Extractables (625/8270) " , Refrigerated?yes Chlorinated:? yes___ no no __ Carbamate Pesticides (531) __ Glyphosate (547) __ Base Neutral Extractables (625/8270) rl'fl __ Diquat (549) -XGC/MS Unknown Scan Free'Chlorine Res:mg/L t __ Chlorination Disinfection Byproducts (551) _ Phthalates (606MS) Total Chlorine Res:_______ mg/L __ Haloacetic Acids: (552) __ Other:_____________ 4 pH j_________ __ Other Pesticides (SMI8/6630) _ UCMR List 1 if 4 RADIOCHEMICAL ANALYSIS __ Radon __MtBE Only (524) 1 __ Other________2___________

INORGANIC ANALYSIS REQUESTED - Lab#: / / / )! 4’ __ Color __ Acidity __ Aluminum __ Potassium __ Turbidity __ Alkalinity Antimony __ Selenium _ pH __ Bromide .. Arsenic __ Silver __ Conductivity __ Bromate/Chlorate/Chlorite Barium __ Sodium __ Corrosivity (temp:. .°C) __ Chloride Beryllium Thallium 1 _ BOD (5 day) __ Cyanide __ Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Zinc __ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOa "CLP M __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*^ __ Metals/CN t. __ Dissolved Oxygen __ 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 ¥ __ Pesticides/PCB’s •, t __ Solids, Percent (%) __ Oil and Grease __ Copper __ Solids, Settleable __ Phenol Iron <1 TCLP __ Solids, Suspended __ Phosphorus Total as P ■? _TCLP-Metals __ Solids, Total __ Phosphorus, Ortho as P __ Magnesi^rn^ __ TCLP-Pesticides __ Solids. Total Dissolved __ Solids, Total Volatile __ Other: -__________ __ Sulfates __ Surfactants _ UV254 __ Manganese").'. __ Mercury Molybdenum __ TCLP-Herbicides __ TCLP-Volatiles i _ TCLP-BNA’s I » ---. Nickel NYC-Wtc_000073387