Chain of Custody Record, Westchester County Dept of Labs

NYC 9/11 Public Portal Document

V/ ■ ENVIRONMENTAL SERVICES^SAMPLE .SUBMISSION.^ORM P t 1/ l x* *CCo ^Uiester WESTCHESTER COUNTY LABORATORIES AND RESEARCH ^-0 2 Dana Road, Valhalla, New York 10595 .. ' . .' , ' (914)231-1620 Fax (914) 231-1772 NYS-ELAP'No. 10108 Time/Date Set: FormX-70 (rev.10/01 )2,.

Sample Type (circle one); 1. Potable :3. Non Potable Treated Bottle #’s: '^."Non Potable 4. Other Chain of Custody? _\es:___ No Time/Date Collected: 'Comments: Collected By: h/b Agency Code: PWS #: _____ Source ID: .Type Descriptor: Collected From: Bill to: Location's/lndividual’s Name Name/Company _ Street_________________ Street_________ City/St/Zip______________ City/St/Zip Identification of Source Phone#:_______ Fax#: Collection Point EHP CA.CH, Bl? Check#: Amounts ~

BACTERIOLOGICAL ANALYSIS Lab#: 2 Lab#:_______________________ ORGANIC POTABLE ANALYSIS / ORGANIC NON POTABLE/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); - __ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) _ Organochlorine Pesticides"'<60W8081) <. __ Microscopic __ Microextractables (504) _ PCB’s (Arochlors) .(608/8081). __ Pesticides/PCB screen (508) _ 'Herbicides (SM18^630,8151) ' __ Macroscopic _ API __ PCB as Decachlorobiphenyl (508A) Other.Pesticides .(SM18/6630), • , __ Other:• __ Herbicides (515) __ ." Petroleurn Hydrocarbon Scan (310-13) __ Pesticides (525) _ Glycols in Water , Refrigerated?yes no __ Carbamate Pesticides (531) Acid Extractables’(625/8270) Chlorinated:?yes no __ Glyphosate (547) _ .Base Neutraf'Extractables (625/8270) _ Diquat (549) _>teC/MS Unknown Scan ’ Free Chlorine Res: . mg/L __ Chlorination Disinfection Byproducts (551) I _ Phthalates (606MS) ■ Total Chlorine Res: _ mg/L __ Haloacetic Acids (552) __ Other:' ■' " ■ ' ■ ’ _Other Pesticides (SMI8/6630) pH ------------------- _UCMRList1 RADIOCHEMICAL ANALYSIS _MtBE Only (524) ' __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color ' __ Acidity __ Aluminum , - __ Potassium ". _ Turbidity __ Alkalinity __ Antimony _ Seleniurn /.; _ pH __ Bromide __ Arsenic _Silver " __ 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. _ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOa __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium,'Ca'+2'.' \ £LP Dissolved Oxygen __ Nitrogen, Nitrate as N .■ _M.etals/CN __ Chromium, Total - / _ '■ __ Volatiles . • __ Total Organic Carbon __ Nitrogen, Nitrite as N ■ .__ Chrprhium, Hexavalent ? Semi-violatiles :__ Total Organic Halides Nitrogen, Total Kjeldahl as N __ Cobalt.. ■ " ’ • ' : Resticides/PCB's _ Solids, Percent' (%)’ __ Oil and Grease __ Copper; _ Solids', Settleable _ Phenol . _ Solids^ Suspended Phosphorus Total as P __ Lead, . ^icLP- , - : ■■<'TGLR-Metals.' ‘ _1 Solids? Total- Phosph'drus; Ortho as P^ _L Magnesium' f_;TCLP?i^stidides, \ . Solids,. Total Dissolved ' Sulfates'. " ' 22'Manganese- . •; ( J^'TCLP-Herbicides^ __ , Solids; TotaLVolatilei __ Surfactants' _ Mercury, . _2. Other:-" .. - --T, „ . ■ v^JCLP-Volatiles^ _,U^2Mr Molybdenum'^ 4 .-_^-TCLP-BNA's __ Nickel] ‘ ■' • 2

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