Chain of custody record, Westchester County Department of Labs &

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM 1 WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914) 231-1620 Fax (914) 231-1772 ^'1 s' ... . - ,__ _____ *''''3 N^ELAPNo. 10108 Time/Date Set: yform A./70 (rev.10/01)

Sample Type (circle one); i 1. Potable 3. Non Potable Treated I Yes No i ■2. on Potable Time/Date Collected: 4. Other Chain of Custody? _ Comments: I Collected By: .^Agency Code: PWS#:________ Source ID; .Type Descriptor: I Collected From: Location’s/lndividual’s Name Street ________ Bill to: Name/Company Street _____ II CIty/St/ZIp City/St/Zip___ Identification of Source Phone#:______ _ — Fax#: 19^ I' Collection Point rCA,CH, Bl? Check#: Amount$__ I t; BACTERIOLOGICAL ANALYSIS I sf; Lab#: ___________ __ Heterotrophic Plate Count (hemodialysis & all others) ORGANIC POTABLE-ANALYSIS __ Trihalomethanes (524) ORGANIC NONPOTABLE/SOLID ANALYSIS _ Purgeable Halocarbons (624/8260) I Coliform P/A (Public supplies) __ Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) <■

_, Coliform MPN (priv well, raw, stp) _ Volatile Aromatics (524) _ Acrolein s Acrylonitrile (8260)

r' __ Fecal Coliform (all samples) __Microscopic _ Macroscopic __ Total Trihaiomethane Potential (510) __ Microextractables (504) __ Pesticides/PCB screen (508) __ PCB as Decachlorobiphenyl (508A) _ Organochlorine Pesticides (608/8081) _ PCB's (Arochlors) (608/8081) _ Herbicide^ (SM18/6830,8151) _ Other Pesticides (SM18/6630) -s

I _ API _ Other_______________ _ Herbicides (515) _ Petoleum Hydrocarbon Scan (310-13) _ Pesticides (525) _ Glycols In Water 1 Refrigerated?yes no __ Carbamate Pesticides (531) _ Add Extractables (625/8270) tmi II ieii.ou; f .. yoo no Base Neutral Extractables (625/8270) _Diquat (549) >^C/MS Unknown Soan- Free Chlorine Res:mg/L __ Chlorination Disinfection Byproducts (551) i _ Phthalates (606MS) Total Chlorine Res:mg/L _HaIoacetic Acids (552) • _ _ OtherL_________ V___________ —— pH ---- ------------ _ Other Pesticides (SM18/6630) _UCMRLi8t1 RADIOCHEMICAL ANALYSIS _MtBE Only (524) _Radon _ Other__________________

INORGANIC ANALYSIS REQUESTED > Lab#: __Color _ Aridity __ Aluminum _ Potassium __ Turbidity __ Alkalinity __ Antimony _ Selenium _ 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 CaCOs __ Calcium, as CaCOs __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca+2 CLE __ Dissolved Oxygen „Metals/CN __ Nitrogen, Nitrate as N __ Chromium, Total _ Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Total Organic Halides _Semi-vlolatiles __ Nitrogen, Total Kjeldahl as N __ Cobalt __ Solids. Percent (%) _ Pesticides/PCB’s __ Oil and Grease __ Copper __ Solids, Settieable __ Phenol __ iron __ Solids, Suspended __ Phosphorus Total as P __ Lead ISiLE _ Solids, Total _TCLP-Metals __ Phosphorus, Ortho as P __ Magnesium _TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates __ Manganese __ Solids, Total Volatile _TCLP-Herbicides __ Surfactante __ Mercury _ TCLP-Volatiles __ Other________________ _ UV254 __ htolybdenun _ TCLP-BNA’s _ Nickel

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