Chain of Custody Record, Westchester County Dept of Labs

NYC 9/11 Public Portal Document

ACCo. ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH A 2'Dana Road, Valhalla, New York 10595 ■ 1I O //W X' (914)231:1620 Fax (914) 231-1772 TimJ/Date Set: NYS-ELAP No. 10108 Form A-70 (rev.10/01) t 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: „ I Collected By:___________ Agency Code: PWS #:________ Source ID: Type Descriptor: 1 Collected From: Bill to: Location’s/lndividual’s Name Name/Company Street________________ !_ Street_________ City/St/Zip______________ City/St/Zip Identification of Source Phone#:_______ Fax#: J. Collection Point CA,CH, Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:_______________________ , ' / i ' "t ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count (hemodialysis & all others) __ Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) __ Coliform P/A (Public supplies) __ Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform MPN (priv well, raw, stp) __ Volatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) ■5 __ 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) 1

__ Other:_____________________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) I __ Pesticides (525) __ Glycols in Water Refrigerated?yes___ no __ Carbamate Pesticides (531) _ Acid Extractables (625/8270) Chlorinated:? yes___ no __ Glyphosate (547) __ Base Neutral Extractables; (625/8270) __ Diquat (549) _('GC/MS Unknown Scan •I Free Chlorine Res: mg/L __ Chlorination Disinfection Byproducts (551) __ Phthalates (606MS) Total Chlorine Res:mg/L __ Haloacetic Acids (552) __ Other:____________________________ pH J------------- __ Other Pesticides (SMI8/6630) _UCMR List 1 RADIOCHEMICAL ANALYSIS __ MtBE Only (524) __ Radon __ Other____________________ 1

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Acidity __ Aluminum __ Potassium I __ Turbidity __ Alkalinity __ .Antimony __ Selenium !' _ pH __ Bromide __; Arsenic __ Silver I __ 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 .i'

_ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOs CLP __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*2 _ Metals/CN __ Dissolved Oxygen __ Nitrogen, Nitrate as N _s’Chromium, Total __ Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Semi-violatiles __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N _rCobalt __ Pesticides/PCB's __ Solids, Percent (%) __ Oil and Grease __ Copper __ Solids, Settleable __ Phenol __ Iron ICLP __ Solids, Suspended __ Phosphorus Total as P __ Lead _TCLP-Metals __ Solids, Total __ Phosphorus, Ortho as P __ Magnesium I i- __ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates __ Manganese __ TCLP-Herbicides __ Solids, Total Volatile __ Surfactants __ Mercury _ TCLP-Volatiles Other:_______ __________ _ UV254 __ Molybdenum _ TCLP-BNA’s I --------------------------------------------- __ Nickel

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