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 • ft 2 Dana Road, Valhalla, New York 10595 (914) 231-1620 Fax (914) 231-1772 I NYS-ELAP No. 10108 I Time/Date Set: Form A-70 (rev. 10/01) ' J

Sample Type (circle one): < T Potable 3. Non Potable Treated Bottle #’s:

2. Non Potable 4. Other_____________ Chain of Custody?___ Yes____ No Time/Date Collected: Comments: Collected By:_____ 1 Agency Code: PWS #:_______ Source ID: Type Descriptor: Bill to: Collected From: 1 Location’s/lndividual’s Name utrv Name/Company I I 1 street____________________ Street_________ City/St/Zip________________ City/SVZip s Identification of Source Phone#: Fax#:

Collection Point _l:________ Check#: Amounts "4 I 'i CA,CH, Bl? I BACTERIOLOGICAL ANALYSIS Lab#: ■a Lab#: __ ________________________ f ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS / __ Heterotrophic Plate Count __ Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) (hemodialysis & 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) , > __ Organochlorine Pesticides (608/8081) ’ y __ Total Trihalomethane Potential (510) __ Fecal Coliform (all samples) __ Microscopic __ Microextractables (504) __ PCB’s (Arochlors) (608/8081) _ Herbicides (SM18/6630,8151) I __ Macroscopic __ Pesticides/PCB screen (508) __ PCB as Decachlbrobiphenyl (508A) __ Other Pesticides (SM18/6630) _ API __ Herbicides (515) s. __ Petroleum Hydrocarbon Scan (310-13) , j __ Other:_______________________

Refrigerated?yes___ no __ Pesticides (525) __ Carbamate Pesticides (531) __ Glycols in Water __ Acid Extractables (625/8270) ; (t . Y -I Chlorinated:?yes___ no __ Glyphosate (547) _ Base Neutral Extractables (625/8270) __ Diquat ’(549) __ GC/MS Unknown Scan Free Chlorine Res:mg/L Total 'chlorine Res:mg/L __ Chlorination Disinfection Byproducts (551) __ Haloacetic Acids (552)' _ Phthalates (606MS) __ Other: ■ i pH J_________ __

RADIOCHEMICAL ANALYSIS __ Other Pesticides (SM18/6630) _UCMRList1 _MtBEOnly (524) I ___Radon __ Other_______________________ ■>..

J INORGANIC ANALYSIS REQUESTED - Lab#: > 'i __ Color __ Acidity -''Aluminum __ Potassium __ turbidity _ pH . __ Alkalinity __ Bromide Antimony ■ Arsenic Selenium __ -Silver ! / I __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium __ Corrosivity (temp: ■ °C) __ Chloride __ ^-Beryllium Thallium _ BOD (5 day) __ Cyanide __ Boron __ Vanadium > r. 'Y __ 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 _ 1 Calcium, Ca*^ __ Dissolved Oxygen __ Total Organic Carbon __ Nitrogen, Nitrate as N __ Nitrogen, Nitrite as N __Chromium, Total __ Chromium, Hexavalent _ Metals/CN __ Volatiles __ Semi-violatiles 1 __ 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 L _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 _r other: -___________ _ UV254 Molybdenum _ TCLP-BNA’s __ ;-Nickel ! NYC-WTC_000073410