Chain of Custody Record, Westchester County Dept of Labs

NYC 9/11 Public Portal Document I

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ACCo ft WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 SI CJ / ■ I O/ ■ I rS*' -v '’5 NYS-ELAP No. 10108, -4 X 1 Time/Date Set: Fo/m A-70 (rev. 10/01)

Sample Type (circle one): 1. Potable 3. Non Potable Treated Bottle #’s: L.' J 3 /Z Non Potable 4. Other Chain of Custody?___ Yes No ''Tirne/Date Collected: Collected By: Agency Code: Comments: PWS #:______ _______________ L Source ID: ■ Type Descriptor: I Collected From: Bill to: ..4 Location's/lndividual’s Name Name/Company Street_________________ City/St/Zip _ ____________ Street_______ City/St/Zip •4 J Identification of Source Phone#: Fax#: < Collection Point CA,CH, Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS Lab#:_______________________ Lab#: ■'1

/ /o / ORGANIC POTABLE'ANALYSIS ' ORGANIC NONPOTABLE/SOLID ANALYSIS . 3 __ Heterotrophic Plate Count (hemodialysis & all others) __ Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) f ■ "S __ Coliform P/A (Public supplies) __ Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) ■j __ Volatile Aromatics (524) __ Acrolein & Acrylonitrile (8260)

3 __ Coliform MPN (priv well, raw, stp) __ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081) __ Microscopic __ Microextractables (504) _ PCB’s (Arochlors) (608/8081) __ Macroscopic _ Pesticides/PCB screen (508) _ Herbicides (SMI8/6630,8151) I __ API __ Other:_____________________ __ PCB as Decachlorobiphenyl (508A) _ Herbicides (515) __ Pesticides (525) __ Other Pesticides (SM18/6630) __ Petroleum Hydrocarbon Scan (310-13) __ Glycols in Water J Refrigerated?yes___ no _ Carbamate Pesticides (531) __ Acid Extractables (625/8270) I Chlorinated:? yes no __ Glyphosate (547) __ Base Neutral Extractables (625/8270) Free: Chlorine Res;mg/L _ Diquat (549) __ Chlorination Disinfection Byproducts (551) GC/MS Unknown Scan _ Phthalates (606MS) ■(

1 Total Chlorine Res:mg/L __ Haloacetic Acids (552) __ Other:__________________________ _Other Pesticides (SMI8/6630) pH J-------------- RADIOCHEMICAL ANALYSIS _UCMR List 1 _MtBEOnly (524) .3 __ Radon s t- Other L

INORGANIC I. ANALYSIS REQUESTED - Lab#: __ Color ./.i __ Aridity __ Aluminum __ Potassium- __ Turbidity __ Alkalinity __ Antimony __ Selenium _ pH __ Bromide __ Arsenic __ Silver __ 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 t. _ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOa CLP __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*^ __ Dissolved Oxygen _ Metals/CN __ 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 __ Solids, Percent (%) __ Oil and Grease __ Copper __ Solids,'"Settleable __ Phenol __ Iron TCLP __ Solids, Suspended __ Phosphorus Total as P _ Lead __ TCLP-Metals __ Solids, Total __ Phosphorus, Ortho as P __ Magnesium __ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates __ Manganese __ TCLP-Herbicides __ Solids, Total Volatile __ Surfactants __ Mercury _ TCLP-Volatiles __ Other:_________________ _ UV254 __ Molybdenum _ TCLP-BNAs if __ Nickel

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