Chain of Custody Record, Westchester County Lab, Feb 2002

NYC 9/11 Public Portal Document

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ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM -Awvstchester WESTCHESTER COUNTY LABORATORIES AND RESEARCH £ 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 ■<

NYS-ELAP No. 10108 Time/Date Set; / . Form A-7b (rev. 10/01)

Sample Type (circle one): , ’t ikW* 1. Potable 3. Non Potable Treated Bottle #’s: _____

. 2. Non Potable 4. Other_____________ Chain of Custody? Yes No'" ■2):/ Comments; Time/Date Collected: Collected By: . 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 Collection Point Phone#:________ Fax#;

CA,CH, Bl? Check#: Amounts

BACTERIOLOGICAL ANALYSIS Lab#: ) Lab#:____________ ______________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count __ Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) (hemodialysis & all others) ,__ Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) __ Volatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) __ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081) __ Microextractables (504) _ PCB’s (Arochlors) (608/8081) __ Microscopic ;-f' __ Pesticides/PCB screen (508) _ Herbicides (SMI8/6630,8151) __ Macroscopic * __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SMI8/6630) __ API __ Other:________________________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) __ Pesticides (525) __ Glycols in Water , ’ ’I Refrigerated?yes no ,__ Carbamate Pesticides (531) __ Glyphosate (547) _ Acid Extractables (625/8270) ‘ __ Base Neutral Extractables. (625/8270)■ Chlorinated:? yes no __ Diquat (549) __ GC/MS Unknown Scan '* Free Chlorine Res; mg/L __ Chlorination Disinfection Byproducts (551) _ Phthalates (606MS) Total Chlorine Res: mg/L ___Haloacetic Acids (552) __ Other:_______________________________ 4'' __ Other Pesticides (SMI8/6630)

i- pH --------------------- _UCMRList 1 , RADIOCHEMICAL ANALYSIS __ MtBE Only (524) t ___Radon I'- __ Other_ _______ ______________

I INORGANIC ANALYSIS REQUESTED - Lab#: __ Color _ Turbidity __ Acidity __ Alkalinity _iAluminum /Antimony __ Potassium Selenium I

_ pH __ Bromide ^Arsenic _j;'Silver __ Conductivity __ Bromate/Chlorate/Chlorite __ ;'Barium __ Sodium ! __ Corrosivity (temp:. °C) __ Chloride z Beryllium ^Thallium | _ BOD (5 day) __ Cyanide __ Boron __ Vanadium ' '■ __ Carbonaceous BOD (5 day) __ Fluoride _Cadmium _/Zinc ' _ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOs CLP ■ __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*2 _ Metals/CN I EM __ Dissolved Oxygen __ Nitrogen, Nitrate as N _iChrornium, Total __ Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N _ Chromium, Hexavalent s' __ Semi-violatiles Its. __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N .^-Cobalt __ Pesticides/PCB's »■__ (Solids,.Percent (%) f__ Oil and Grease ■ ^Copper --2: "Solids,'Se^able, - "sft__ Phenol fe' J □(’/Solidis^^^^Sed , , Phosphorus Total as P _;1ron _^'Lead icLP _TCLP-Metals : I __ Phosphorus, Ortho as P __ Magnesium __ TCLP-Pesticides. Sulfates .'Manganese __ TCLP-Herbicides -• Mercury __ TCLP-Volatiles Molybdenum _ TCLP-BNA’s __ Nickel (

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