Chain of Custody Record, Westchester County Dept of Labs

NYC 9/11 Public Portal Document i I ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 r? (914)231-1620 Fax (914) 231-1772 / NYS-ELAP No. 10108 Time/Date Set: Form A-70 (rev. 10/Op

Sample Type (circle one): i 1 1.-Potable 3. Non Potable Treated Bottle #'s: 2.‘ Non Potable 4. Other Chain of Custody?___ Yes___ No Time/Date Collected: Comments: 5' Collected By: j Agency Code: PWS #:______ ■ Source ID: Type Descriptor: 1 Collected From: Lbcation’s/lndividual’s Name ; Bill to; Name/Company i3 1 Street__________________ City/St/Zip______________ Street_______ City/St/Zip J ..I r Identification of Sou rce Phone#: Fax#: J Collection Point I CA,CH, Bl? Check#; Amounts

BACTERIOLOGICAL ANALYSIS Lab#: Lab#: -____________________ __ ’ Heterotrophic Plate Count ORGANIC POTABLE ANALYSIS __ Trihalomethanes (524) ORGANIC NONPOTABLE/SOLID ANALYSIS __ Purgeable Halocarbons (624/8260) -1 (hemodialysis & all others) i __ .■Coliforrn P/A (Public supplies) __ Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) _ ) Coliforrn MPN (priv well, raw, stp) __ Volatile Aromatics (524) _ ; Acrolein & Acrylonitrile (8260) __ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081) i- __ (Microscopic __ Microextractables (504) _ PCB’s (Arochlors) (608/8081) ‘i.’

__ . Macroscopic __ Pesticides/PCB screen (508) _ Herbicides (SM18/6630,8151) I-

API , __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SMI8/6630) __ Other:_____________________ __ Herbicides (515) ___ Petroleum Hydrocarbon Scan (310-13) ■ __ Pesticides (525) Glycols in Water '■ Refrigerated? yes no __ Carbamate Pesticides (531) __ Acid Extractables (625/8370) , Chlorinated:? yes no __ Glyphosate (547) - Base Neutral Extractables (625/8270) ( __ Diquat (549) __ GC/MS Unknown Scan Free Chlorine'Res: . mg/L __ Chlorination Disinfection Byproducts (551) _ Phthalates (606MS) I Total Chlorine Res: . mg/L __ Haloacetic Acids (552) __ Other:t I _ Other Pesticides (SMI8/6630) pH ___________ _UCMRList1 1 RADIOCHEMICAL ANALYSIS _ MtBE Only (524) __ Radon i'- __ Other____________________ 1 INORGANIC ANALYSIS REQUESTED - Lab#: AZ? __ Color __ Acidity / Aluminum __ Potassium 4 - Turbidity __ Alkalinity __ ^'Antimony __ Selenium ■ 1 — pH __ Bromide • Arsenic __ Silver * I '• Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium _L Corrosivity (temp:. _ BOD (5 day) °C) __ Chloride __ Cyanide __ Beryllium __ Boron _ Thallium 1 1 > Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Vanadium __ Zinc f "J __ Soluble BOD (5 day) ' Chemical Oxygen Demand ' Dissolved Oxygen __ Hardness, Total as CaCOs __ Nitrogen, Ammonia as N __ Nitrogen, Nitrate as N __ Calcium, as CaCOa __ Calcium, Ca*^ j^Chromium, Total CLP _ Metals/CN 1 ' Total Organic Carbon __ Volatiles __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Total Organic Halides __ Semi-violatiles __ Nitrogen, Total Kjeldahl as N __ Cobalt . Solids, Percent (%) __ Pesticides/PCB’s 'J __ Oil and Grease __ Copper _i Solids, Settleable __ Phenol __ Iron TCLP $ _1 Solids, Suspended __ Phosphorus Total as P __ Lead _r Solids, Total _TCLP-Metals __ Phosphorus, Ortho as P __ Magnesium _1 Solids, Total Dissolved __ TCLP-Pesticides __ Sulfates "4. __ Manganese i Solids, Total Volatile __ TCLP-Herbicides __ Surfactants Mercury ' Other: . __________ _ TCLP-Volatiles _ UV254 __ Molybdenum _ TCLP-BNA’s __ Nickel

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