Chain of Custody Record, Westchester County Lab, Mar 2002

NYC 9/11 Public Portal Document

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

6. Sample Type (circle one); I

, 1. Potable 3. Non Potable Treated Bottle #’s: 2. Non Potable 4. Other Chain of Custody?___ Yes No 1 Time/Date Collected:___________ Comments:

I Collected By;____________ Collected From: Agency Code: PWS #:______ Bill to; Source ID: Type Descriptor:

Location’s/lndividual's Name Name/Company Street_________________ Street________ I f City/St/Zip '_______ City/St/Zip , Identification of Source Phone#: Fax#:__________ S’.. I Collection Point 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) b I __ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) __ Org'anochlorine Pesticides (608/8081) __ Microextractables (504) __ PCB's (Arochlors) (608/8081) V __ Microscopic _ Pesticides/PCB screen (508) __ Herbicides (SM18/6630,8151) __ Macroscopic _ API __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SM18/6630) __ Other:__________ __________ __ Herbicides (515) __ Petroleum 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 Neutral Extractables (625/8270) __ 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:__________ __ Other Pesticides (SMI8/6630) pH __ _________ __ UCMR List 1 RADIOCHEMICAL ANALYSIS _MtBEOnly (524) __ Radon I __ Other____________________

INORGANIC ANALYSIS REQUESTED • Lab#: __ Color __ /Acidity Aluminum __ Potassium __ Turbidity _ _Alkalinity Antimony _i Selenium * __ Bromide __ Arsenic _iL'Silver _ pH __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium' T. Corrosivity (temp: ’C) __ Chloride __Beryllium _v‘'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 __ Dissolved Oxygen __ Nitrogen, Nitrate as N ^Chromium, Total __ Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent' __ Semi-violatiles __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N __ Cobalt __ Pesticides/PCB's __ Solids, Percent (%) __ Oil and Grease __ Copper __ Solids, Settleable __ Phenol __ Iron TCLP __ Solids, Suspended __ Phosphorus Total as P __ Lead _TCLP-Metals __ Solids, Total __ Phosphorus, Ortho as p __ Magnesium TCLP-Pesticides (■ __ Solids, Total Dissolved __ Sulfates __ Manganese TCLP-Herbicides f__ Solids, Total Volatile __ Surfactants __ Mercury ' TCLP-Volatiles , Other:_________________ _ UV254 __ Molybdenum _ TCLP-BNA’s _ Nickel

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