Chain of Custody Record, Westchester County Dept of Labs

NYC 9/11 Public Portal Document

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ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ,MfestGhester I WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914) 231-1620 Fax (914) 231-1772 'I 1 "I NYS-ELAP No. 10108 . Time/Date Set: Form A-70 (rev. 10/01)1 , .V t

Sample Type (circle one): / ■1 1..Potable 3. Non Potable Treated Bottle #’s: - ' 3 U- 2. Non Potable 4. Other Tinie/Date Collected:_____ ____________ Chain of Custody? 'Yes Comments: No 1 Collected By: ' Agency Code: PWS #:_________ __ Source ID: Type Descriptor: Collected From: Bill to: 1 Location’s/lndividual's Name Name/Company 1 til Street_________________ Street_____________ City/St/Zip______________ City/St/Zip__________ 4 Identification of Source Phone#:_____ Fax#: J Collection Point CA.CH, Bl? Check#: Amounts

) J' BACTERIOLOGICAL ANALYSIS Lab#:______________ ________ Lab#: / / -f I ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ ^’Heterotrophic Plate Count ■

j (hemodialysis & all others) __ Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) . __ Coliform P/A (Public supplies) _ I Coliform MPN (priv well, raw, stp) __ Fecal Coliform (all samples) __ Volatile Halocarbons (524) __ Volatile Aromatics (524) __ Total Trihalomethane Potential (510) __ Purgeable Aromatics (624/8260) , __ Acrolein & Acrylonitrile (8260) __ Organochlorine Pesticides (608/8081) ’k ' 3 Microscopic __ Microextractables (504) _ PCB’s (Arochlors) (608/8081) _ Macroscopic __ 'Pesticides/PCB screen (508) _ Herbicides (SMI8/6630,8151) ■ _L API Other:____________________ __ PCB as Decachlorobiphenyl (508A) __ Herbicides (515) __ Pesticides (525) _ Other Pesticides (SM18/6630) __ Petroleum Hydrocarbon Scan (310-13) . " 1 Refrigerated?yes I Chlorinated:? yes no no __ Carbamate Pesticides (531) __ Glyphosate (547) __ Glycols in Water _ Acid Extractables (625/8270) ' Base Neutral Extractables (625/8270) ■■ ■f,',,.-. Q , „ I Free Chlorine Res: . mg/L __ Diquat (549) __ Chlorination Disinfection Byproducts (551) __: GC/MS Unknown Scan _ Phthalates (606MS) K', J Total Chlorine Res: . mg/L __ Haloacetic Acids (552) __ Other Pesticides (SMI8/6630) __ Other:•• 1 P? ----------- _UCMR Listi I RADIOCHEMICAL ANALYSIS _MtBE Only (524) Radon _J. Other_______ ____________

'INORGANIC ANALYSIS REQUESTED - Lab#: __ Color I_ Turbidity ■_ pH __ Acidity __ Alkalinity __ Bromide Aluminum __ Antimony __ Arsenic __ Potassium __ Selenium Silver •. .f -

s-I _ Conductivity __ Bromate/Chlorate/Chlorite Barium __ Sodium *-''7 i'7 •4 __ Corrosivity (temp: °C) __ Chloride __ Beryllium __ Thallium ! V (' /' ! ■a )_ BOD (5 day) __ Cyanide __ Boron __ Vanadium (__ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium Zinc i ■ j__ Soluble BOD (5 day) __ Chemical Oxygen Demand j__ Dissolved Oxygen __ Hardness, Total as CaCOa __ Nitrogen, Ammonia as N __ Nitrogen, Nitrate as N __ Calcium, as CaCOa __ Calcium, Ca*2 __ Chromium, Total CLP^ _ Metals/CN __ Volatiles 3 __ Total Organic Carbon __ Nitrogen, Nitrite as N __ 'Chromium, Hexavalent __ Semi-violatiles __ Total Organic Halides __ Solids, Percent (%) I__ Solids, Settleable ■__ Solids, Suspended __ Nitrogen, Total Kjeldahl as N __ Oil and Grease __ Phenol __ Phosphorus Total as P __ Cobalt __ Copper __ Iron __ Lead J ICLP Pesticides/PCB’s I __ TCLP-Metals :__ Solids, Total __ Solids, Total Dissolved . __ Solids, Total Volatile __ Phosphorus, Ortho as P __ Sulfates __ Magnesiurh __ Manganese __ TCLP-Pesticides __ TCLP-Herbicides j 1 __ Surfactants __ Mercury Other: _________ _ TCLP-Volatiles _ UV254 __ Molybdenum :. NYC-WTC_000073414 __ Nickel _ TCLP-BNA’s I