Sample submission form, Aug 2001

NYC 9/11 Public Portal Document ' ■ _

Wacthadt, ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM 8 WtWoVCODl WESTCHESTER COUNTY LABORATORIES AND RESEARCH OWB -> ' ' 2 Dana Road, Valhalla, New York 10595 828 Time/Date Set: E3"T$E33:12a162204sR84SE212X Sample Type (circle one): 1. Potable' / 3. Non Potable Treated teeuiuh)g3sen;u3h,632/K05/3) Bottle #s33(79seXo/c400L_ 2. Non Potable 4. Other ....... : Chain of Custody? yes no Time/Date Collected: 1> i * Comments: Collected By: A Agency Code: PWS#:_ : Source ID: Type Descriptor: Collected .From: Bill to: Location’s/Individual's Name — Name/Company Street / — — Street ...... , City/St/Zip ______ __________ City/St/Zid Identification of Source ... ........ ■ Phone#: _ Fax#: Collection Point Ao j i 6 CA.CH, Bl? Check#: Amounts

ve° BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS if Lab#: ______________ ________ Lab#: ................ .......... -__ — (circle tests) (circle tests) 1. Heterotrophic Plate (1) Trihalomethanes (524) : 1. Purgeable Halocarbons (624/8260) Count (hemodialysis & all others) (2.) Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260) 2. Coliform P/A (public supplies) (3) Volatile Aromatics (524) L 3. Acrolein & Acrylonitrile (624) 3. Coliform MPN (priv well, raw, stp) 4. Total Trihalomethane Potential 0) . ...4. Phthalates (625/8270) 4. Fecal Coliform (all samples) (5) Microextractables (504) “ 5. Organochlorine Pesticides (608/8081)

• - : SF6sHCS6sscScraon(50s) & PCB as Decachlorobiphenyl (508A) — %- itftfmmttnnn 6. PCB’s (Arochlors) (608/8081) ■

8. Herbicides (EPA1978/8151) — D 2 Pesticide! (21) % Pesticides (M18/6630).... 1 SS H^^'sean (310-13) Refrigerated? ___ _yes ___ no fl 17 Carbamate Pesticides (531) + 11. Glycols ==i= Chlorinated:? yes no (12) Glyphosate (547) 12: Acid Extractables (625/8270) a i® (13) Diquat (549) 13. Base Neutral Extractables (625/8270) ". T Free Chlorine Res mg/L Total Chlorine Res: ............ mg/L 4. Chlorination Disinfection Byproducts (551) 15. Haloacetic Acids (552) 14. GC/MS Semivolatile Unknown Scan 15. Purgeable Halocarbons (DEF) SIH 16. Pesticides (SM18/6630) 16. Purgeable Aromatics (DEF) pH ' - 17. Petroieum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB's (DEF) s 18.) Other: S‘. ‘ a ‘ 1 .. 18. Other:______ _________

INORGANIC ANALYSIS REQUESTED - Lab#: 11 (circle tests) 1. Color 20. Acidity 39. Aluminum 59. Potassium 2. Turbidity 21. Alkalinity, as CaCOs 40. Antimony 60. Selenium 3.pHne 22. Bromide 41. Arsenic 61. Silver 4. Conductivity 23. Bromate/Chlorate/Chlorite 42. Barium 62. Sodium 5. Corrosivity (temp: °C) 24. Chloride 43. Beryllium 63. Thallium 6. BOD (5 day) 25. Cyanide 44. Boron 64. Vanadium 7. Soluble BOD (5 day) 26. Fluoride 45. Cadmium 65. Zinc 8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOa 46. Calcium, as CaCOa CLP 9. Chemical Oxygen Demand ------------------------ 48.Chromium, Total 66.Metals/CN 28. Nitrogen, Ammonia as N 47. Calcium, Ca*2 10. Dissolved Oxygen 11. Total Organic Carbon 29. Nitrogen, Nitrate as N 49. Chromium, Hexavalent _ 67. 30. Nitrogen, Nitrite as N s - 50.CoM Volatiles oapeS'caSreB ’s 1 12. Total Organic Halides 31. Nitrogen, Total Kjeldahl as N / - ■ 13. Solids, Percent (%) 32. Oil an Grease 4 Solids, Settleable 33. Phosphorus Phenol 52 IroPP olids. Suspended . 34. P- — " " Total as P 23 Lena TCLP 1id

#.pnoSBROrus Onalp ou 54Maon-Xm 1 TCLP-Metals 1= T 2 ... " . 1818. * Solids f i* ‘Sill r' ___ Total Vnl ■ ^siXXnts 38. UV254 *; ' syr J"Tu) . . ____ _ J-L: 2 14____ __ ■ il— a y

NYC-WTC_000025775