Chain of custody record, Westchester County Department of Labs &

NYC 9/11 Public Portal Document

■Il \1 r ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ^icstcr WESTCHESTER COUNTY LABORATORIES AND RESEARCH \roiii fl 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 NYS-ELAP No. 10108 Time/Date Set: Form A-70 (rev. 10/01)

Sample Type (circle one); 1. Potable 2. Non Potable 3. Non Potable Treated^ 4. Other Time/Date Collected;__________ ; Bottle #-s:.

Chain of Custody?___ Yes Comments: . No I i Collected By:_________ _______ Agency Code: ........ ....... .... ..... ....... PWS #: Source ID:Type Descriptor; ___ Coliocted From; Bill to; Location’s/lndividual’s Name; ......................................... ... 8 Namo/C'Vmvinv Street________________________ ; .Street City/St/Zip_________________ ____________________________ _____ City/St/Zip : __________ ___________ ___ Phone#: ___J ■I identification of Source Fax#: J

I Collection Point............................... ________ CA.CH, Bl? _ „ Check#: Amount$

I BACTERIOLOGICAL ANALYSIS Lab#:.________________________ Lab#; _____L__±4————__ -

I 8 ___ Heterotrophic Plate Count (hemodialysis & all others) __ Coliform P/A (Public supplies) ORGANIC POTABLE ANALYSIS __ Trihalomethanes (524) _ Volatile Halocarbons (524) ORGANIC NONPO TABLE/ SOLID ANALYSIS __ Purgeable Halocarbons (624/8260) __ Purgeable Aromatics (624/8260) __ Coliform MPN (priv well, raw, stp) __ Volatile Aromatics (524) _ Acrolein & Acrylonitrile (8260) __ Fecal Coliform (ail samples) __ Total Trihalomethane Potential (510) „ Organochloririe Pesticides (608/8081) __ Microscopic __ Microextractabiss (504) PCB’s (Arochlors) (608/8081) __Macroscopic __ Pesticides/PCB screen (508) _ Herbicides (SM18/6630,8151) — API __ PCB as Decachlorobiphenyl (508A) Other Pesticides (SMI 8/6630) _ Other: ________________, _ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) Pesticides (525) _ Glycols in Water Refrigerated?yes no __ Carbamate Pesticides (531) __ Acid Extractables (625/8270)

■I Chlorinated:?yes no __ Glyphosate (547) ___ Sase Neutral Extractables (625/8270) __ Diquat (549) GC/MS Unknown Scan Free Chlorine Res:____ .j . mg/L __ Chlorination Disinfection Byproducts (551) . Phthalates (606MS)

Ie Total Chlorine Res: pH --------- mg/L: __ Haloacetic Acids (552) __ Other Pesticides (SM18/6630) __ UCMR List 1 __ Other:

R AD !OC H E M !C AL A NA i Y SI S MtBE Only (524) i■ Radon __ Other_________________________

INORGANIC ANALYSIS REQUESTED - i.ah#. ■

IIB __ Color __ Acidity __ Aluminum _ Potassium __ Turbidity __ Alkalinity __ Antimony __ Selenium — pH __ Bromide __ Arsenic __ Silver __ Conductivity __ Bromate/Chlorate/Chlofite __ Barium __ Sodium Corrosivity (temp :____°C) __ Chloride __ Beryllium __ Thallium |MI .. BOD (5 day) __ Cyanide __ Boron Vunadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Zinc ___ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOs IB __ Chemical Oxygen Demand __ Dissolved Oxygen __ Total Organic Carbon __ Nitrogen, Ammonia as N __ Nitrogen, Nitrate as N __ Nitrogen, Nitrite as N __ Calcium. Ca*^ __ Chromium, Total __ Chromium, Hexavalent „ Metais/CN __ Volatiles ■ __ Semi-vioiatiies

I■ __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N ___ Cobalt __ Pesticides/PCB's __ Solids, Percent (%) _ Oil and Grease __ Copper BIBII . .. Solids, Settleable __ Phenol _ Iron TCLP __ Solids, Suspended __ Phosphorus Total as P _ Lead _TCLP-Metals __ Solids, Total ___ Phosphorus, Ortho as P __ Magnesium ___TCLP-Pes«ddes -So«dsrTi3taH3lssol*e^--------- ... Sotfates’ ..... 'Manganese.. ..... - _TCLP-Herbicides _ Solids, Total Volatile Siir'niJants __ Mercury __ TCLP-Volatiles __ Other:____________________ _ UV254 __ Molybdenum ___ TCLP-BNA's _ Nickel . .. NYC-WTC_000075116