Chain of custody record, Westchester County Department of Labs &

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM -•'i WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914) 231-1620 Fax (914) 231-1772 J4YS-ELAP No. 10108. - 3 Time/Date Set; ^^^orm A-70 (rev.lO/OI)

ipieType (circle one): Bottle #’s:_____ 2 l^otable 3. Non Potable Treated 2. Non Potable 4. Other Chain of Custody? Yes.__ No Time/Date Colled^:: A Comments:____ 1 Collected By: Agency Code: PWS #: _ ______ Source ID: Type Descriptor: 1 Collected From: Bill to:

1-.- Location’s/indlvidJii's Name, Name/Company _ I Street ' '' City/St/Zip_____________ identification of Source Street:_______ _ City/St/Zip Phone#:______ Fa)^: i Collection Point

I CA,CH, Bl? . „ > Check#: Amount$

11 I BACTERIOLOGICAL ANALYSIS Lab#: _______ _ _ Heterotrophic Plate Count Lab#: ORGANIC POTABLE ANALYSIS ORGANIC NONpOTABLE/SOLID ANALYSIS 'I r (hempdialysis & all others) Coliform P/A* (Public supplies) _ Coliform MPh (priv well, raw, stp) __ Trihalomethanes (524) _ Volatile Halocarbons (524) __ Volatile Aromatics (524) __ Purgeable Halocarbons (624/8260) _ Purgeable Aromatics (624/8260) __ Acrolein & Awylonitrile (8260) I .w _ Fecal Coliforrn (all samples) Microscopic __ Total Trihalomethane Potential (510) __ Microextractables (504) _ Organochldrine Pesticides (608/8081) ■- _ PCB's (Arochlors) (608/8081) S _ PestIcides/PCB screen (508) _ Herbicides (SM18/6630,8151) / I L. Macroscopic API Other: , I- __ PCB as Decachlorobiphenyl (508A) _ Herbicides (515) _ Other Pesticides, (SM18/683d) __ Petroleum Hydrocarbon Scanf (310-13) :} _ Pesticides (525) _ Glycois In Water Refrigerated? yes no __ Carbamate Pesticides (531) _ Acid Extractables (625/8270) f .^GlyphGsate(547)----- ---------------------— /I Chlorinated:? yes no Free Chlorine Res:.______ .mg/L _Diquat (549) __ Chlorination Disinfection Byproducts (551) _ Phthalates (606MS) •w Total Chlorine Res: _______mg/L _Haloacetlc Acids (552) _ Other & _Other Pesticides (SM18/6630) pH-____ ____ _UCMRUst1 RADIOCHEMICAL ANALYSIS _Radon _MtBE Only (524) I _ Other __ _________ __

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color _ Acidity 5;^^uminum __ Potassium _ Turbidity _ Alkalinity JifAntimony j^i^ienium __ pH __ Bromide ,<jS<Ar8enic .jif^ilver __ Conductivity , __ Bromate/Chlorate/Chlorite JSodium __ Corrosivity (temp:. ’C) _ Chloride 24,j^ryllium <2^Thal|lum _ BOD (5 day) __ Cyanide __ Boron Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium .^Zlnc _ 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 \.„rfChromlum, Total _ Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Total Organic Halides __ Semi-violatiles _ Nitrogen, Total Kjeldahl as N _ Pesticides/PCB's _ Solids, Percent (%) _ Oil and Grease popper _ Solids, Settleable __ Phenol Z/ron __ Solids, Suspended __ Phosphorus Total as P ^Lead ISLE _TCLP-Metals _ Solids, Total __ Phosphorus, Ortho as P _ Magnesium _TCLP-Pestlcides _ Solids, Total Dissolved __ Sulfates SBj^anganese j^ercury _TCLP-Herbicides _ Solids, Total Volatile __ Surfactants _ TCLP-Volatlles pother-------------------- _ UV254 _TCLP-8f5lAs

NYC-WTC_000074998