Chain of Custody Record, Westchester County Dept of Labs

NYC 9/11 Public Portal Document f I s ACCo ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM & WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 /I' YCmUXS (914)231-1620 Fax (914) 231-1772 stUKa^ X

! NYS-ELAP No. 10108 Time/Date Set: Form A-70 (rev.10/01) ,,; '^1

Sample Type (circle one): 1. Potable 3. Non Potabie Treated Bottle #’s:_________________ 2. Non Potable 4. Other Chain of Custody?___ Yes___ No •■'I Time/Date Collected: 3' , Comments: t Collected By: Agency Code: PWS #:______ Source ID: Type Descriptor: Collected From: . Bill to: "1 Loc'ation’s/lndividuaTs Name r ■ Name/Company Street_________________ Street______ _ City/St/Zip______________ City/St/Zip Identification of Source Phone#: Fax#: Collection Point CA,CH, Bl? Check#: Amounts I '1 BACTERIOLOGICAL ANALYSIS Lab#: ./ V / V Lab'#:__________________ __ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS

1: __ 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) __ [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) X /_ API __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides’ (SMI8/6630) ■.'"f __ Other:_____________________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) I __ Pesticides (525) __ Glycols in Water ’ , y. Refrigerated?yes___ no __ Carbamate Pesticides (531) _ Acid Extractables (625/8270) ..a Chlorinated:? -yes___ no __ Glyphosate (547) __ Base Neutral Extractables (625/8270) L, / Free Chlorine Res:mg/L _ Diquat (549) ' j^'GC/MS Unknown Scan I __ Chlorination Disinfection Byproducts (551) __ Phthalates (606MS) Total Chlorine Res:mg/L pH ___________ _ Haloacetic Acids (552) __ , Other Pesticides (SMI8/6630) _UCMRList 1 __ Other: I (RADIOCHEMICAL ANALYSIS __ .Radon __ Other____________________ _MtBE Only (524) 1 1 INORGANIC ANALYSIS REQUESTED - Lab#. t I I ’ *

Color __ Acidity _j/Aluminum __ Potassium - / __ Turbidity __ Alkalinity -<^ntimonv _^Sglenium ‘ J_ pH __ Bromide jxArsenic '• .-'Silver ■ J ■ J 4-"-. J_ Conductivity __ Bromate/Chlorate/Chlorite _:_i'Barium 2:^Sodium Corrosivity (temp:“C) __ Chloride ^'Beryllium -Thallium J_ BOD (5 day) __ Cyanide __ Boron __ Vanadium _ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium Jrr'Zinc _ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOs "CLP I . Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca+2 __ Dissolved Oxygen _Metals/CN __ Nitrogen, Nitrate as N _L;Cftromium, Total __ Volatiles ■ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Semi-violatiles Total Organic Halides __ Nitrogen, Total Kjeldahl as N _u-C/balt __ Pesticides/PCB's __ Solids, Percent (%) __ Oil and Grease .-'Copper j_ Solids, Settleable __ Phenol _^lran TCLP Solids, Suspended __ Phosphorus Total as P _L;'Lead _TCLP-Metals __ Solids, Total __ Phosphorus, Ortho as P __ Magnesium __ TCLP-Pesticides ;_ Solids, Total Dissolved __ Sulfates _L;-Manganese __ TCLP-Herbicides ‘4 :_ Solids, Total Volatile __ Surfactants Mercury ._^''6ther: __________ __ TCLP-Volatiles _ UV254 _LfN4olybdenum _ TCLP-BNA’s j^Nickel

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