Sample submission form, Aug 2001

NYC 9/11 Public Portal Document ■111 iiUKiititK&lissaxafgflf^ * ......... v . . ’ ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM . V 1 ** ... com WESTCHESTER COUNTY LABORATORIES AND RESEARCH III 7 'ads ' 2 Dana Road, Valhalla, New York 10595 t ■1 94)593-5575 * 34 344, c9) NYS-ELAP No. 10108 ime/Date Set: £231,223^21^1^ le Type (circle one): /206 4,24 0.2, : s <) al,v(G 3. 2 L 24 2) / 1. Potable 3. Non Potable Treated Bottle #’s: 599/(8,46)036,31) 9c92,00 ) / 6/7) 2. Non Potable 4. Other ................... ............. ....... Chain of Custody? yes no Time/Date Collected: _ Comments: _ Collected By: _ Agency Code: PWS #: _ Source ID: Type Descriptor: Collected From: ? ■ — • — Bill to: : \ Location’s/ndividual’s Name........................................... . Name/Company _ Street .. .............. . ........ . ........................... ..... ..... ......... ..... ... •Street _ City/St/Zip ____ -. _. :. -. . -.. . City/St/Zip _ Identification of Source................ ................................... - Phone#: _____ Fax#: Collection Point ' 2 ______ __ CA,CH, Bl? Check# Amounts

BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS Lab#; _ _______ ____ ______ __ ____ - Lab#: . .......................... .. ...... ............ (circle tests) (circle tests) . .. : (1 Trihalomethanes (524) n } l' 1. Purgeable Halocarbons (624/8260) 1. Heterotrophic Plate Count (hemodialysis & all others) (2) Volatile Halocarbons (524) ‘i • 2. Purgeable Aromatics (624/8260) 2 2. Coliform P/A (public supplies) (3 Volatile Aromatics (524) 4 3. Acrolein & Acrylonitrile (624) 1

i blgsseegsso?“t80“l1(508) .. .. 3. Coliform MPN (priv well, raw, stp) 4 Total Trihalomethane Potential-(510) -4. Phthalates (625/8270) - '

tol samples) 5.Pcenododno,ysta8rso8sp8808v) 9 M 7 Methoprene(616) . ' P d. .2 ■ s9 ^Refrigerated?------- yes _ no I I 2 _ _ eny,(508A) _ *YY g:Besticides(SRA29885351) 10. Petroleum Hydrocarbon Scan (310-13) 11.Glycols-% ! _______________ yes__.no 712. Glyphosate (547) 12. Acid Extractables (625/8270) 7 J (13) Diquat (549) 13. Base Neutral Extractables (625/8270) fil Free Chlorine Res: mg/L 14. Chlorination Disinfection Byproducts (551) 14. GC/MS Semivolatile Unknown Scan 1. r 15. Haloacetic Acids (552) 15. Purgeable Halocarbons (DEF) j tal Chlorine Res: mg/L A 17. pSSeum/Hydro^ (181 Other: 5V8 + .............................. 16. Purgeable Aromatics (DEF) - 17. pesticidesiPCBs ppp (PPY (DEF) 18. Other:.. -...... —......... -........ —.. L MPC

"INORGANIC ANALYSIS REQUESTED - Lab#: i (circle tests) _ 0905 1. Color 090/620. Acidity 1-39. Aluminum 6 59. Potassium 2. Turbidity 21. Alkalinity, as CaCO3 40. Antimony 60. Selenium 3.pH 4. Conductivity 022. Bromide 23. Bromate/Chlorate/Chlorite 41Arsenic 42. Barium 61. Silver 62. Sodium 5. Corrosivity (temo: SC) 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 d i 9. Chemical Oxygen Demand” 28. Nitrogen, Ammonia as N 8. Carbonaceous BOD (5 day)

10. Dissolved Oxygen 27. Hardness, Total as CaCOs

29. Nitrogen, Nitrate as N 46. Calcium, as CaCOa 47. Calcium, ca" 48. Chromium, Total CLP 66.Metals/CN 1 67. Volatiles 11. Total Organic Carbon 30. Nitrogen, Nitrite as N 49. Chromium, Hexavalent sill 68.Semi-violatiles ... . 1 51.Copper sssix i 12. Total Organic Halidas 31. Nitrogen, Totai Kjeldahi as N 50.Cobait 12 sSolids, Percent (9) • 10 32Ol an Grease f: @ _ . HIUO. ° _ 10d 34 _ SS PhoSomlortHsl 53 Iron M Magnesium I TCLP 7... i 1TCLP-Metals.., OUoUtSIIUcU

173 JSST 35 ManganS 72.TOLP-Pesticides l 1 ' y 18. S 37. Surtactants 56.Mercury 73.TCLP-Herbicides 74 TCLP-V 5*" (Bu3 19. C ■ _ 122_______1221_____ 1' 75. TCLP-BN

NYC-WTC_000025776