Sample submission form, Aug 2001

NYC 9/11 Public Portal Document

s 9 W1. es's ’ ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ' - OV. WESTCHESTER COUNTY LABORATORIES AND RESEARCH ' 2 Dana Road, Valhalla, New York 10595 ?■ ; 1 i (914) 593-5575 • ’ : s / ) NYS-ELAP No. 10108 i me/Date Set: 4..... -. -.......... sample Type (circle one): 1 ,910-24*88011/7v56somA-79/r8v.1/96) e3385231,%77)0201m)80Z0Sy020r) —_ .Potable ' 3. Non Potable Treated Bottle #s.(6176 } 6) 26 2)c ‘8,1-93/92)% t#.') . Non Potable 4. Other __________ Chain: of Custody? yes no Time/Date Collected: _____________ ______ ______ 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 ..... ....... . i..................... ;............ —___ __ City/St/Zip Identification of Source ;....... .... ... . -. , .. .. —... .... : Phone#: _____ Fax#: Collection Point ' 2 2 (. H _.. _.... CA,CH, BI? Check#:’. Amounts,

BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS Lab#: _ _______ _______________ La^__ — _ — | | (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) C3. Volatile Aromatics (524). . 3. Acrolein & Acrylonitrile (624) 3. Coliform MPN (priv well, raw, stp) 4. Total Trihalomethane Potential (510) .4. Phthalates (625/8270) 5) Microextractables (504) "5. Organochlorine Pesticides (608/8081)

’ YasroscoP ■='m fm9n 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151) ■ 9. Herbicides (515) 9. Pesticides (SM18/6630) nemngoratec?_yes_no chorinated:?yes no xp. Pesticides (525) #11. Carbamate Pesticides (531) 712 Glyphosate (547) 10. Petroleum Hydrocarbon Scan (310-13) 11. Glycols 12. Acid Extractables (625/8270) . m —’ 13: Diquat (549) 13. Base Neutral Extractables (625/8270) Free Chlorine Res: mg/L 14. Chlorination Disinfection Byproducts (551) 14. GC/MS Semivolatile Unknown Scan Total Chlorine Res: - mg/L 15. Haloacetic Acids (552) , 15. Purgeable Halocarbons (DEF) • . 16. Pesticides (SM18/6630) 16. Purgeable Aromatics (DEF) pH _ __________ 17. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB’s (DEF) 18. Other: 1 ' . . x - =———_------------------------__—-—----------—-------- • 18. Other: / . _ • :. ........ <. — — 1 INORGANIC ANALYSIS REQUESTED - Lab#: (circle tests) 1. Color 20. Acidity . : 39. Aluminum 59.Potassium 2. Turbidity 21. Alkalinity, as CaCO3 : 40. Antimony ■ ■ 60. Selenium 3. pH 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 CaC03 46. Calcium, as CaCO3 CLP 9. Chemical Oxygen Demand 28. Nitrogen, Ammonia as N 47. Calcium, Ca*2 %6.Metals/CN 10. Dissolved Oxygen 29. Nitrogen, ...... Nitrate as N 48. Chromium, Total 67. Volatiles 11. Total Organic Carbon 30. Nitrogen, Nitrite as N 49. Chromium, Hexavalent 68. Semi-violatiles 12. Total Organic Halides 31. Nitrogen, Total Kjeldahl as N 50.Cobalt 69.Pesticides/PCB’s 13. Solids, Percent (%) 20 32. 011 an Grease 5opper --- 70. Disk Deliverables 5 1 1. Solids, Settleable 033. Phenol 200//52.tronn00 ICB — (Solids, Suspended 34. Phosphorus Total as P 53.Lead . 71TCLP-Metals “Solids, Total. ,. 35 Phosphorus, Ortho as P sz it sr 72.TCLP-Pesticides 73.TCLP-Herbicides 74. TCLP-Volatiles .......... _ _ _ - 75.TCLP-BNAS _____ __________

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