Chain of Custody Record, Westchester County Dept of Labs

NYC 9/11 Public Portal Document I

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM .^estehester WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914) 231-1620 Fax (914) 231-1772 ^neHci'- : NYS-ELAP No. 10108 / Time/Date Set: Form A-70 (rev.10/01) * 4 \ .-'iT

Sample Type (circle one): •TY (/ 1. Potable 3. Non Potable Treated Bottle #’s: i 3 2. Non Potable 4. Other______________________ Chain of Custody?___ Yes No _

I Time/Date Collected: Comments: Collected By:' ___________ Agency Code: 1 PWS #:______ Source ID: Type Descriptor: J Collected From: Bill to: I Location’s/lndividual’s Name . \J Name/Company Street _________________ Street________ I. -I City/St/Zip_____ ________ City/St/Zip ■I Identification of Source Phone#: Fax#: Collection Poirit ■ L I> I CA,CH, Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS Lab#: 3/ Lab#:“_______________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS < __ Heterotrophic Plate Count __ Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) f 3 (hemodialysis & all others) 1 & __ Coliform P/A' (Public supplies) __ Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform MPN (priv well, raw, stp) _ Volatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) __ 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 (SM18/6630,8151) _ API __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SM18/6630) __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) __ Other:_____________________ Refrigerated?yes___ no I ’

Chlorinated:? yes___ no __ Pesticides (525) __ Carbamate Pesticides (531) __ Glyphosate (547) __ Glycols in Water _ Acid Extractables (625/8270) ,’ __ Base Neutral Extractables (625/8270) ,, .3 1 _ 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:___________________________ pH ------------------- __ Other Pesticides (SM18/6630) _UCMR List 1 t I RADIOCHEMICAL ANALYSIS __ MtBE Only (524) __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: / 7-j ./ • __ Color __ Acidity __ Aluminum __ Potassium / (■» __ turbidity __ Alkalinity __ Antimony __ Selenium 5 _ pH __ Bromide __ Arsenic __ Silver __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium I __ Sodium __ Corrosivity (temp:. °C) __ Chloride __ Beryllium -__ Thallium, ' i t _ BOD (5 day) __ Cyanide __ Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Zinc ‘ _ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOa "CLP __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca+2 J _ Metals/CN __ 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 __ 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-BNA’s I ________________________________ __ Nickel -4

NYC-WTC_000073408