Chain of Custody Record, Westchester County Dept of Labs

NYC 9/11 Public Portal Document

I . ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM AVestchester WESTCHESTER COUNTY LABORATORIES AND RESEARCH 4

I 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 IC r '4 NYS-ELAPNo. lOlOe-r Titrie/Date Set: Form A-70 (rev. 10/01) .1 Sample Type (circle one): Z1.■Potable 2.(Non Potable 3. Non Potable Treated 4. Other Bottle #’s: Chain of Custody? Yes 7^

No J Time/Date Collected: Comments: Collected By: C- J; Agency Code: PWS #: Source ID: Type Descriptor: f L t Collected From: Bill to: Location’s/lndividual’s Name ! Street____________________ City/St/Zip________________ Name/Company _ Street__________ City/St/Zip i' j I

i Identification of Source Phone#:________ Fax#: .i Collection Point CA,CH, Bl? Check#: Amounts. I

a BACTERIOLOGICAL ANALYSIS Lab#: Lab#:-_____________________ ■ .-ft-*, ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS , __ Heterotrophic Plate Count __ Trihalomethanes (524) __:• Purgeable Halocarbons (624/8260) (herhodialysis & all others) __ Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) __ Volatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) "__ Fecal ,Coliform (all samples) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081) __ Microextractables (504) _ PCB’s (Arochlors) (608/8081) S? , Microscopic __ Pesticides/PCB screen (508) _ Herbicides,(SM18/6630,8151) __ Macroscopic 4

1 _'API __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SMI 8/6630) __ Other:_______________________ _ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13)" ‘ __ Pesticides (525) __ Glycols in Water ' jRefrigerated?yes___ no __ Carbamate Pesticides (531) __ Acid Extractables (625/8270) ■1 . ''Chlorinated:? yes___ no __ Glyphosate (547) __ Base Neutral Extractables (625/8270) V __ Diquat (549) 1 v/ GC/MS Unknown Scan ,Free Chlorine Res:_________ mg/L __ Chlorination Disinfection Byproducts (551) '___.Phthalates (606MS) T, Total Chlorine Res:'mg/L __ Haloacetic Acids (552) other:. 'i.j

' 1-. J __ Other Pesticides (SMI8/6630) pH _UCMRList 1 RADIOCHEMICAL ANALYSIS __ MtBE Only (524) ___ Radon'^ Li:

__ Other ' v- _______________ I INORGANIC ANALYSIS REQUESTED - Lab#: / f __ Color __ Asidity Aluminum __ Potassium __ ’ Turbidity __ Alkalinity Antimony _2i.,Selenium pH __ Bromide :• Arsenic _v’Silver _ Conductivity __ Bromate/Chlorate/Chlorite Barium __ Sodium Corrosivity (temp:. °C) __ Chloride 21 Beryllium Thallium 2 __ BOD (5 day) __ Cyanide __ Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium 21 Zinc __^Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOs CLP ■ __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca+2 __ Dissolved Oxygen _ Metals/CN j __ Nitrogen, Nitrate as N ilChromium, Total __ Volatiles __ ■ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent J ' __ Semi-violatiles __ '.Total Organic Halides __ Nitrogen, Total Kjeldahl as N __ Cobalt __ Pesticides/PCB’s ■t __ Solids, Percent (%) __ Oil and Gre'ase _i_ Copper __ .Solids, Settleable __ Phenol Iron 1

__ 'Solids, Suspended TCLP __ Phosphorus Total as P 2^ Lead _TCLP-Metals __ Solids, Total __ Phosphorus, Ortho as P __ Magnesium __ TCLP-Pesticides __ I Solids, Total Dissolved __ Sulfates t- Manganese __ 'Solids, Total Volatile __ TCLP-Herbicides __ Surfactants Mercury ! _ TCLP-Volatiles 2^ (Other: . _ UV254 i_ Molybdenum ■1 _ TCLP-BNA’s .1 Nickel .1 - ------------------ I NYC-WTC_000073388