Chain of custody record, Westchester County Department of Labs &

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM Sf'Otll WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 ■1 ■ NYS-ELAPNo. 10108 1 Time/Dale Sof form A-7Q (rev. 10/01) ------------------------------------------------------------- i T VX.-1 - ----- —---------- -------— Sample Type . < ! i (I. Potable/ 3. Non Potable Treated Bottle 2. Non Potable 4. Other Chain of Custody?Yes No Time/Date Collected Comments:_______ __________________________________ i Collected By: Collected From. Agency Code: PWS #:___ ...___ ____ Source ID:Type Descriptor:i Bill to; ■ Location’s/individuai's Name Name/Company ■ Street Street City/St/Zip______________ ....__________ ________________ City/St/Zip Identification of Sourc^__^_______________________________ Phone#: _ _____ Fax#: j

Collection Point CA,CH, Bl? Check#:Amounts ________ i i lill I BACTERIOLOGICAL. ANALYSIS Lab#: —-47- IIIIBIIllllllllllllllBBIBBBIIIIIIIlfcllBliMllBll Lab#:________________________ __ Heterotrophic Plate Count ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE,'SOLID ANALYSIS ■ i __ Trihalomethanes (524) _ Purgeable Halocarbons (624/8260) (hemodialysis & all others) __ Coliform P/A (Public supplies) __ Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) _ Acrolein & Acrylonitrile (8260) ■ __ Coliform MPN (priv well, raw, stp) __ Volatile Aromatics (524) __ Fecal Coliform (all samples) _ Microscopic __ Total Trihalomethane Potential (510) __ Microextractabies (504) Orqanochlorine Pesticides (608/8081) _ RGB's (Arochlors) (608/8081) ■ Herbicides ISM lii/6630,8151)

11 __ Macroscopic _ API „. Other:_____ ______________ __ Pesticides/PCB screen (508) __ PCB as Decachlorobiphenyl (508A) ... I ie'bicides fhlfn __ Other Pesticides (SMI8/6630) I’elrokiiim 1 Ivdrocnrbon Senn {310-13) i■ ___ Pesticides (525) Glycols in Water Refrigerated?yes no __ Carbamate Pesticides (531) __ Acid Extractables (625/8270) 11 Chlorinated;? ... yes no __ Glyphosate (547) __ Base Neutral Extractables (625/8270.) i Free Chlorine Res:mg/L Diquat (549) __ Chlorination Disinfection Byproducts (551)^ _ GC/MS Unknown Scan _ Phthalates (606MS) 1 Tn-ni Chlorine Rns:............. mq'L pH-------------- —-______________ __ Haloacetic Acids (552) __Other Pesticides (SMI8/6630) _„UCMRLisl1 __ Other: ___ ___ I RADIOCHEMICAL. ANALYSIS” "^ _MtBE Only (524) __ Radon ... Other__ __________________

1 iNORGANiC ANALYSIS REQUESTED -1 a:#/ IBII __ Color _ Acidity y Aluminum _ . Potassium __ Turbidity _ Alkalinity 7 Antimony 7 Selenium pH . Bimnidf! ZZ Arsenic ./ Silver __ Conductivity __ Bromate/Chlorate/Chiorite / Barium __ Sodium __ Corrosivity (temp:„ BOD (5 day) ?C); Chloride __ Cyanide Beryllium __ Boron 7. Thallium Vanadium ■I __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium 7. Zinc Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOa __ Chemical Oxygen Demand ___ Nitrogen, Ammonia as N Calcium, Ca+2 . Z Chromium, Total _ Metals/CN __ Dissolved Oxygen __ Nitrogen, Nitrate as N ... . Volatiles __ Total Organic Carbon _ Nitrogen, Nitrite as N Chromium, Hexavalent __ Semi-violatiles __ Total Organic Halides .. ... Nitrogen, Total Kjeldahl as N 7 Cobalt ... PotUioides/PCBs' __ Solids, Percent (%) __ Oil and Grease .4 Copper __ Solids, Settleabie __ Solids. Suspended _ Solids, Total

Solids, Total Volatile .... __ Phenol __ Phosphorus Total as P __ Phosphorus, Ortho as P

_ Surfactants ..., 7 Iron jZ Lead Magnesium ■/.YT/Ianganese 7 Mercury ' ICLP _TCLP-Metals TCI _ TCLP-Herbicides ■ii J Z. other: _______ __ TCLP-Voiatiles _ UV254 7. Molybdenum _ TCLP-BNAs .' Nu-ke! —J NYC-WTC_000075115