Chain of custody record, Westchester County Department of Labs &

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 asSM «»2

^S-ELAP No. 10108 ' Time/Date Set: "Form A-70 (rev.lO/Ol) -7:* e-- QZ^

% ploTypo (drde one): otable 2. Non Potable Tlme/Date Collected: Collected By: K Collected From: 3. Non Potable Treated 4. Other _________________

Location’s/lndlvidual’s Name ___ . .Street __ ____ ________________ ■ ‘

Agency Code: j ' ■, Bottle#’si^ Chain of Custody?Yes _— No Commente:'_______ ______ PWS#:;_____ Bill to: Name/Company Street—____ < y...,,

Source ID: .Type Descriptor: I s 'i City/St/Zip—_—_____________ City/St/ZIp Identification of Source.. " Phone#: Fax*

I Collection Point________ I CA,CH, Bl? Amounts al Check#:'. I if BACTiERIOLCGICAL ANALYSIS Lab#: " ? — Heterotrophic Plate Count Lab#: ORGANiC.POTABLE ANALYSIS ORGANIC NONPOTABLEZSOUD ANALYSIS I (hemodialysis & an others) — Coliform P/A (Public supplies) — Coliform MPN (priv well, raw, stp) __ Trihalomethanes (524) — Volatile Halocarbons (524) __ Volatile Aromatics (524) __ Total Trihalomethane Potential (510) — Purgeabie Halocarbons (824/8260) — Purgeable Aromatics (624/8260) — Acrolein & Acrylonitrile (8260) Y _ _Organochlorine Pesticides (608/8081) x - I — Fecal Cotlform (all samples) 'v Microscopic __ Mjcroextractables (504) _j PCB'& (Arochlors) (608«081) ._ Macroscopic _ API — Other:_____________ ' Refrigerated?yes Chlorinated:? ... ves no no __ Pesticides/PCB screen (508) — PCB as Decachlorobiphenyl (508A) -Herbicides (515) __ Pesticides (525) __ Carbamate Pesticides (531) — Herbicides (SM18/6630,8151) — Other Pesticides (SMI8/6630) — Petroleum Hydrocarbon Scan (310-13) — Glycols In Water — Acid Retables (625/8270) —Glyphosate (547)—------------------------- ——WeNeutralExtractables(625/8270)-— —Diquat (549) _jfe*GC/MS Unknown Scan I Free Chlorine Res:_ mg/L __ Chlorination Disinfection Byproducts (551) — Phthalates (606MS) Total Chlorine Res:. mg/L __ Haioacetic Acids (552) — Other:_____ — PH._— RADIOCHEMICAL ANALYSIS —Other Pesticides (SM18/6630) —UCMR Usti — MtBE Only (524) I __Radbn _ Other _ ________________

INORGANIC ANALYSIS REQUESTED - Lab#: _ Color __ Acidity Y^umlnum ’otassium _ Turbid!^ _ Alkalinity ^^^Antimony elenium _PH __ Bromide j^Arsenic liver __ Conductivity _ Bromate/Chlorate/Chlorite ^Barium todium _ Corrosivity (temp:. “C) — Chloride _i^§eryllium -^STha Ilium — BOD (5 day) __ Cyanide __ Boron adium- __Carbonaceous BOD (5 day) __ Fluoride __ Cadmium — Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOs _ Chemical Oxygen Demand CLP Nlt^en, Ammonia as N — Cgidium, Ca*2 — Dissolved Oxygen __ Nitrogen, Nitrate as N — Metals/CN jfciCnromium, Total __ Volatiles __Total Organic Carbon —JMitrogen, Nitrite as N mium, Hexavalent __ Total Organic Halides __ Semi-violatiies — Nitrogen, Total Kjeldahl as N __Solids, Percent (%) _ Pesticides/PCB’s __ Oil and Grease __ Solids, Settleabie __ Phenol __ Solids, Suspended TCLP Jj'Phosphorus Total as P __Solids, Total _TCLP-Metals __ Phosphorus, Ortho as P Magnesium _TCLP-P8sticides __Solids, Total Dissolved __ Sulfates « j^jWanganese __ ^ids. Total Volatile _TCLP-Herblcides __ Surfactants » < .i^rdS^ercury __ TCLP-Volatiles .i/Other ' ______ — UV254 _TCLP-BNA’s

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