Chain of Custody Record, Westchester County Dept of Labs

NYC 9/11 Public Portal Document

I i ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ‘ IS ACCn, -.Westchester WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 ^/1 11 "'I (914) 231-1620 Fax (914)231-1772 ’"i NYS-ELAPNo. 10iq8<.; Time/Date Set: Form A-70 (rev. 10/01) ’ I

i- .. < Sample Type (circle one): Bottle #’s: >- 1. Potable :3. Non Potable Treated 2. Non Potable 4. Other___________ Chain of Custody? Yes___ No .4 Time/Date Collected: I /M Comments: J Collected By: C Agency Code: PWS #: Source ID: Type Descriptor: 3 Collected From: Location's/lndividual’s Name '7 Bill to: Name/Company _ I Street_________________ street_________ ■s ’■

City/St/Zip______________ City/St/Zip Identification of Source Phone#:_______ Fax#: Collection Point-» CA,CH, Bl? Check#: Amounts Ji BACTERIOLOGICAL ANALYSIS Lab#: / I Lab#:___________________ __ - ' / ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID AN ALYS IS'-( __ Heterotrophic Plate Count __ Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) ■4 (hemodialysis & all others) __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) __ Volatile Halocarbons (524) __ Volatile Aromatics (524) __ Total Trihalomethane Potential (510) __ Purgeable Aromatics (624/8260) __ Acrolein & Acrylonitrile (8260) _ Organochlorine Pesticides (608/8081) '.i.

4 I __ Fecal Coliform (all samples) y-'i - __ Microextractables (504) • _ PCB’s (Arochlors) (608/8081) __ Microscopic __ Macroscopic _ API __ Pesticides/PCB screen (508) __ PCB as Decachlorobiphenyl (508A) _ Herbicides (SMI8/6630,8151) __ Other Pesticides (SM18/6630) IK 1 __ Other:____________________ Refrigerated?yes no __ Herbicides (515) __ Pesticides (525) __ Carbamate Pesticides (531) __ Petroleum Hydrocarbon Scan (310-13)' __ Glycols in Water __ Acid Extractables (625/8270) ‘ I Chlorinated:? Free Chlorine Res: I yes no . mg/L __ Glyphosate (547) __ Diquat (549) __ Chlorination Disinfection Byproducts (551) __ Base Neutral Extractables (625/8270) ’ GC/MS Unknown Scan _ Phthalates (606MS) 5- !T< 1.- ‘3 I Total Chlorine Res: . mg/L __ Haloacetic Acids (552) __ Other:__________________________ pH]__________ __ Other Pesticides (SM 18/6630) __ UCMR List 1 RADIOCHEMICAL ANALYSIS __ Radon __ Other ________________ _ MtBE Only (524) V 1' INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Acidity _i_ Aluminum __ Potassium J __ Turbidity __ Alkalinity '' Antimony Selenium > pH __ Bromide ’ Arsenic Silver '' j "<4 __ Conductivity __ Bromate/Chlorate/Chlorite 2^ Barium __ Sodium ' ' __ Corrosivity (temp:. “C) __ Chloride Beryllium Thallium _i BOD (5 day) __ Cyanide __ Boron <_ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium i- Zinc Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOa CLP __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca+2 _ Metals/CN _ I Dissolved Oxygen _ _ Nitrogen, Nitrate as N i^’Chromium, Total __ Volatiles _ ! Total Organic Carbon _ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Semi-violatiles __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N V Cobalt __ Pesticides/PCB’s _ Solids, Percent (%) _ Solids, Settleable _l Solids, Suspended __ Oil and Grease __ Phenol __ Phosphorus Total as P ' Copper Iron Lead II

TCLP r I _TCLP-Metals __ Solids, Total __ Phosphorus, Ortho as P __ Magnesium __ TCLP-Pesticides y _J. Solids, Total Dissolved __ Sulfates __ Manganese __ TCLP-Herbicides _L Solids, Total Volatile __ Surfactants _ .Mercury _ TCLP-Volatiles t other: •..'.■•J _ UV254 __ Molybdenum 3 _ TCLP-BNA’s r Nickel

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