Chain of custody record, Westchester County Department of Labs &

NYC 9/11 Public Portal Document

I ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM A ; aiAli S^COj, .

ivcom WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595/'- j I- (914)231-1620 Fax(914)231-1772 lx

It- Htne/Date Set: _ ___ w NYS-ELAPNo.10108 Form A-70 (rev. 10/01)

Ik (J Sample Type (circle one); potable 3. Non Potable Treated Bottle #’s:

I 2. Non Potable Time/Date Collected: Collected By: Collected From: -4. Other y i

Jr Agency Code: Chain of Custody? Comments: PWS#: Bill to: Yes No

Source ID: .Type Descriptor A'

Location’s/indlvlduars Name Name/Company F Street _________ Street ______ _ City/St/Zip______ _ City/St/23p____ Identification of Source Phone#: Tsodk. Collection Point I CA,CH, Bl? Check#: Afhoun^

BACTERIOLOGICAL ANALYSIS Lab#: ________ Lab#:_ I I __ Heterotrophic Plate Count ORGANIC POTABLE ANALYSIS __ Trihalomethanes (524) ORGANIC NONPOTABLE/SOLID ANALYSIS

1I (hemodialysis & all others) Purgeable Halocarbons (624/8260) __ Coiiform P/A (Public supplies) _ Volatile Halocarbons (624) __ Purgeable Aromatics (624/8260) _ Coliform MPN (prlv well, raw, stp) __ Volatile Aromatics (524) _ Acrolein & Acrylonitrile (8260) 3 ,. !?■ Fecal Coliform (all samples) _ Total Trihalomethane Potential (510) _ Organochlorine Pesticides <(608/8081) Microscopic __ Microextractables (504) PCB^ (Arochlors) (608/8081) Macroscopic __ Pesticides/PCB screen (508) _ Herbicides (SM18/6630,8151) ? •3 __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SM18/6630) B ■ 5 API 3 i Other ____ _ Refrigerated?. Chiprinsted;?^ . yes no .yBS_no- _ Herbicides (515) _ Pesticides (525) __ Carbamate Pesticides (531) _Giyphosate(547)_______________ __ __ Petroleum Hydrocarbon Scan- 010-13) __ Glycols in Water Acidlxtiactables (825/8270) v _ BaseNeutrai Extractables (625/8270)' . S’"

'S I _Diquat (549) l/GC/MS Unknown Scan Free Chlorine Res;_______ mg/L __ Chlorination Disinfection Byproducts (551) _ Phthalates (606MS) p IbtarchlorineRes:: • mg/L __Haloacetic Acids (552) _ Ofoer:____________j__;£_. _ Other Pesticides (SM18/6630) _UCMRLlst1 RADIOCHEMICAL ANALYSIS _MtBE Only (524) i _Radon Other _

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color _ Turbidity — pH „ Acidity „ Alkalinity Bromide Aluminum ^Antimony .ICArsenic __ Potassium jfSelenlum J^SSIlver I-1 _ Conductivity „ Bromate/Chlorate/Chlorite _Sodium _ Corrosivity (temp:_____ °C) „Chloride _£3eryllium lef Thallium _ BOD (5 day) Cyanide __ Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride _ Cadmium _ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Caldum.as CaCOs __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calciurn.Ca*^ cEF ':. __ Dissolved Oxygen __ Nitrogen, Nitrate as N . „Metals/CN Ji. Chromium. Total „ Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N Cobalt __ Semi-violatiles _ Solids, Percent (%) __ Oil and Grease __Pesticides/PCB’8 _±:Copper _ Solids, Settleable __ Phenol V Iron 'K, __ Solids, Suspended _ Phosphorus Total as P JlLead I£LE _ Solids, Total _TCLP-Metals __ Phosphorus, Ortho as P __ Magnesium __ Solids, Total Dissolved __ TCLP-Pesticides _ _ Sulfates _^Manganese _ Solids, Total Velatile __ Surfactants _TCLP-Herbicides _i'Mercury' j, _ TCLP-Volatiles js!f Olhen _______ _ UV254 , _L Molybdenurn \ _TCLP-BNA’s _4^Nickel

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