Chain of Custody Record, Westchester County Lab, Mar 2002

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM 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-70 (rev. 10/01)

Sample Type (circle one): (l. Potable 3. Non Potable,Treated Bottle #’s: / ' ' —

2..Non Potable 4. Other Chain of Custody? Yes___ No ,, • Time/Date Collected: / / ' Comments: •s

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 t Phone#:________ Fax#: Collection Point CA,CH, Bl? Check#: I 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) ___ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081) __ Fecal Coliform (all samples) __ Microextractables (504) __ PCB’s (Arochlors) (608/8081) 5 , __ Microscopic __ Pesticides/PCB screen (508) _ Herbicides (SMI8/6630,8151) __ Macroscopic __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SMI8/6630) _ API __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) _ Other:_______________________ __ 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) ci __ Diquat (549) _L-GC/MS Unknown Scan Free Chlorine Res: . mg/L __ Chlorination Disinfection Byproducts (551) __ Phthalates (606MS) Total Chlorine Res: - mg/L __ Haloacetic Acids (552) __ Other:________________________________ ? pH _____________ __ Other Pesticides (SM18/6630) _UCMRList 1 t

rr RADIOCHEMICAL ANALYSIS ___ Radon __ Other_______________________ _MtBEOnly (524)

I ■ INORGANIC ANALYSIS REQUESTED - Lab#: r

r __ Color __ Acidity Aluminum __ Potassium •._ _ Turbidity __ Alkalinity Antimony L Selenium — pH __ Bromide ■ Arsenic _ Silver !•__ Conductivity __ Bromate/Chlorate/Chlorite ~ Barium __ Sodium L Corrosivity (temp: °C) __ Chloride Beryllium ■ Z_ Thallium

I _ BOD (5 day) __ Carbonaceous BOD (5 day) _ Soluble BOD (5 day) __ Chemical Oxygen Demand __ Cyanide __ Fluoride __ Hardness, Total as CaCOs __ Nitrogen, Ammonia as N __ Boron __ Cadmium __ Calcium, as CaCOs __ Calcium, Ca+2 __ Vanadium i Zinc CLP^ _Metals/CN..

Ls, _ Dissolved Oxygen __ Nitrogen, Nitrate as N Jr:jChromium, Total _ Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Sem i-violatiles , __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N Cobalt __ Pesticides/PCB’s __ Solids, Percent (%) _ Oil and Grease Copper I- __ Solids, Settleable __ Solids, Suspended __ Phenol __ Phosphorus Total as P _ Iron t Lead tclp

i __ Solids, Total __ Solids, Total Dissolved Solids, Total Volatile ___Phosphorus, Ortho as P __ Sulfates __ Surfactants __ Magnesium _ Manganese " Mercury _TCLP-Metals __ TCLP-Pesticides __ TCLP-Herbicides

E ___ TCLP-Volatiles ' ■ Other: _________ _ UV254 Molybdenum _ TCLP-BNA's ' Nickel

L

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