Chain of custody record, Westchester County Department of Labs &

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM Z^***!!^®*- WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New Ybrk 10595 yY S/Tl '3g (914)231-1620 Fax (914) 231-1772 <LBJ ,------ ------ y Z NYS-ELAP No. 10108 4 Time/Date Set: Y Form A-70 (rev. 10/01) " ' 7?

Sample Type (circle one): ,. ^^^otable 2. Non Potable 3. Nori Potable Treated 4. Other Bottle #-8: (9 - r /W. Chain of Custody? Yes..__ No s Time/Date Collected: _ ■~T777~T;rrT'T Comments: 1 Collected By: Agency Code: PWS#:._______ __ Source ID: .Type Descriptor: Collected From: BUI to: ■ Location’s/lndivldual’s Name __ Name/Compahy 3 Street ______________ Str^t ________ , CIty/SOp City/St/Zip _____ 3 Is Identification of Source Phone#: -Y''... Fax#: 4 "•1 Collection Point rCA,CH, Bl? Check#: __ Amounts. s BACTERIOLOGICAL ANALYSIS Lab#: •3 'Lab#: ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SbLip ANALYSIS I i X Heterotrophic Plate Count ' (hemodialysis & all others) _Trihalomethanes (524) __ Purgeabie Halocarbons (624/8260) \v-n-

X Coliform P/A (Public supplies) ‘X Coliform MPN (priv well, raw, stp) _ Volatile Halocarbons (524) __ Volatile Aromatics (524) _ Total Trihalomethane Potential (510) _ Pur^ble Aromatics (624/8260) _ Acrolelrt &Acrylonitftle (8260) : f _ Organochlorine Pesticides (808/8081) 1 X Fecal Coliforrn (all samples) __ Microscopic l_Microextractables (504) _L. Pesticides/PCB screen (508) PCB’s (Arochlors) (608/8081) : _ H8rbicides (SM18/6630,8151) I f; X Macroscopic _ API X Q^er _________________ _ _ PCS as Decachlorobiphenyl (508A) _ Herbicides (515) _ Other Pesticides (SM18/6630) . __ Petroleum Hydrocarbon Scan (310-13) ■I Refrigsrated? yes no __ Pesticides (525) _ Glycols in V\ferter " IS Chlorlnat6d:? vBs no — __ Carbamate Pesticides (531) (SIvnhoftfttA yJSifTX______ _ _ Acid Extractables (625/8270) - .;_;BaseNeutraiExtraetables<625«^^^ J I Free Chlorine Res: • mg/L _ Diquat (549) __ Chlorination Disinfection Byproducts (551) [ XaC/MS Unknown Scan __ Phthalates (606MS) Total Chlorinri Res:mg/L _Haloacetic Acids (552) '_ Other _ Other Pesticides (SM18/6630) ____________ _UCMRList1 RADIOCHEMICAL ANALYSIS _MtBE Only (524) ‘ ■I- ■3 __Radon Other ____________

INORGANIC ANALYSIS REQUESTED - Lab#: _ Color _ Acidity 5:^7; _Y'*Alumlnum __ Potassium _ Turbidity __ Alkalinity YrAntimony _iG81enium, _ pH __ Bromide Arsenic _irSliver _ Conductivity . __ Bromate/Chlorate/Chlorite _^'B^um __ Spdium :_ Corrosivity (temp:____“C) __ Chloride .beryllium , _fcflTiallium _ 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 __ Cajpium, Ca*2 CLE __ Dissolved Oxygen __ Nitrogen, Nitrate as N _^Oriromium, Total __M8tals/CN __ Total Organic Carbon __ Volatiles __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N __ Semi-violatiles UsrCpbalt __ Pesticides/PCB's _ Solids, Percent (%) __ Oil and Grease Copper _ Solids, Settleable __ Phenol _ Solids, Suspend^ TCLP Phosphorus Total as P____ _;L'ead _TCLP-Metals __ Solids, Total __ Phosphorus, Ortho as P __ Magnesium _ Solids, Total Dissolved _TCLP-Pesticidos __ Sulfates _ur'l^nganese _ Solids, Total Volatile _TCLP-Herblcldes _ Surfactants ^i-Wlercury _X)ther:__m__________ _ UV254 _^*lVdybdenum _TCLP-Volatlles _TCLP-BNAs __J^ckel

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