Chain of Custody Record, Westchester County Dept of Labs

NYC 9/11 Public Portal Document

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ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 1 NYS-ELAP No. 10108 Time/Date Set: Form A-70 (rev. 10/01)

Sample Type (circle one): 1. Potable 3. Non Potable Treated Bottle #'s: 2. Non Potable 4. Other Chain of Custody? Yes___ No Time/Date Collected: Comments: Collected By: ' Agency Code: PWS #:________ Source ID: Type Descriptor: Collected From: Bill to: Location's/lndividual’s Name Name/Company _ Street_________________ Street_________ 4 City/St/Zip______________ City/St/Zip Identification of Source Phone#:_______ Fax#: ,b Collection Point CA,CH, Bl? Check#: Amounts.

i -BACTERIOLOGICAL ANALYSIS Lab#: tab#:_______________________ ! ! L-. 4 ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS Heterotrophic Plate Count ? (hemodialysis & all others) __ Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) i

__ Coliform P/A (Public supplies) __ Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) ILt Coliform MPN (priv well, raw, stp) __ Volatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) ^®!;ecal 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 (SMI8/6630) Other:__________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) __ Pesticides (525) __ Glycols in Water ^Refrigerated?yes no __ Carbamate Pesticides (531) __ Acid Extractables (625/8270) ^Chlorinated:? yes __ Glyphosate (547) __ Base Neutral Extractables (625/8270) no __ Diquat (549) __ GC/MS Unknown Scan Free Chlorine Res: . mg/L __ Chlorination Disinfection Byproducts (551) _ Phthalates (606MS) -Total Chlorine Res: . mg/L __ Haloacetic Acids (552) __ Other:____________________________ __ Other Pesticides (SMI8/6630) __ UCMR List 1 I WRADIOCHEMICAL ANALYSIS _MtBEOnly (524) K Radon I Mother________________ I •INORGANIC ANALYSIS REQUESTED - Lab#: 1 Color __ Acidity __ Aluminum __ Potassium Turbidity __ Alkalinity __ Antimony __ Selenium fepH __ 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 __ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOa CLP __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*2 _ 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-BNAs __ Nickel

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