Sample submission form, Aug 2001

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM

Ill Westchester County WESTCHFSIFE comNr t ARORATQRES ANHFGi r"CH 2 Dana Road. Valhalla, New York 10595 (914) 593-5575 NYS-ELAP No. 10108 Form A-70 (rev, 1/96), Dmei ’ ___ •+ tple Type (circle one): ?/.. . 6 2* 21405 ■ ■ . 4** « 1- Potable. • 3. Non-Potaple Treated -. ■ Bottle #‘s:. . __ 2. Non-Potable 4. Other_ Chain of Custody? ■ ' no . Time/Date Collected: 2 t s 6J.. . _ _ Comments:___ Collected By:"azoiskoAann Collected From: 1 Agency Code:________ - PWS #: Bill to: SourcelD: Type Descriptor Location's/Individual’s NameMr Name/Company. 7 Street S... vdl lo ... ... ........... . ........ ... ......................... Street City/St/Zip y/ - h ALa 1/ .... _. __.... . ..... ... .... ; City/St/Zip. Identification of Source .......— _______Phone#: - Fax# Collection Point = 16 4 ±/326____ (___________ _ CA,CH,BI? Check# Amounts. : .* ' —.: " rmn BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES Lab #_ Lab#: . . (circle tests) ‘ /,/ (circle tests) Trihalomethanes (524) ' 1 1 2 1. Heterotrophic Plate 1. Purgeable Halocarbons (624/8260) Count (hemodialysis & all others) Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260) 2. Coliform P/A (public supplies) Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624) 3. Coliform MPN (priv well, raw, stp) 4, Total Trihalomethane Potential (510) 4. Phthalates (606/8060) 4. Fecal Coliform (all samples) (5.) Microextractables(504) 5. Organochlorine Pesticides (608/8080) X Pesticides (507) " 6. PCB's (Arochlors) (608/8080) 7.2 Pesticides/PCB screen (508).... __________ __________ _____ 7. -. Herbicides (SM-18/6640; 8151) - CC a Other - PCB as Decachlorobiphenyl (508A)

30.P6sticides(525) 192 Herbicides (515) Hydrocarbon Scan (310-13) 9.10. PetGlyrcololesumin Water 8, Other Pesticides (SM-18/6630)

.. Refrigerated? _ __ yes____ no ,11 Carbamate Pesticides (531) —11 .Acid Extractables (625/8270) >12 Glyphosate (547) . 12. Base Neutral Extractables (625/8270) _ — (13 Chlorinated?: _ . Diquat uo (549)_ .13. GC/MS Unknown Scan 14. Chlorination Disinfection Byproducts (551) 14. Purgeable Halocarbons (DEF) em — 0001................... FreeChiorineRes-----m9/- —m9- 1 15. Haloacetic Acids (552) 15. Purgeable Aromatics (DEF) 16. Other Pesticides (SM-18/6630) 16. Pesticides (DEF) Total Chlorine Res: ' ma/L 17. Petroleum/Hydrocarbon Scan (310-13) 17. PCB’s (Arochlors) (DEF) /—99/19090/ pH__ 998) /6 / 3 INORGANIC ANALYSES REQUESTED - Lab#: (circle tests) 1. Color 20. Acidity 39. Aluminum 59. Potassium

ur* 4.Conductivity 22:8!oahv-ascacor aR.Artomcnv 23. Bromate/Chlorate/Chlorite42. Barium 60. Selenium 61. Silver 62. Sodium 5.Corrosivity (temp: °C) 24. Chloride 43 Beryllium - 163.Thalliumem 6.7. BOD(5day) , 25.Cyanide Boron. _ 4445.Cadmrum 64Vanadun6 8. soluble BOD (5 day) Carbonaceous BOD (5 day) 26. Fluoride _ 27. Hardness, Total as CaCO3 46. Calcium, as CaCO3 CLP 9. Chemical Oxygen Demand 28. Nitrogen, Ammonia as N 47. Calcium, Ca*2 66. Metals/CN I 10. Dissolved Oxygen i 11. Total Organic Carbon 29. Nitrogen, Nitrate as N 30. Nitrogen, Nitrite as N 48. Chromium, Total 49. Chromium, Hexavalent 67. Volatiles 68. Semi-volatiles | 12. Total Organic Halides 31. Nitrogen, Total Kjeldahl as N 50. Cobalt 69. Pesticides/PCB’s | 13. Solids, Percent (%) 32. Oil and Grease 51. Copper 70. Disk Deliverables I SoMs, Settleable 33. Phenol 52. Iron TCLP ] geaSolids, Suspended 34. Phosphorus, Total as P 53. Lead 71. TCLP-Metals I “T Solids, Total 35. Phosphorus, Ortho as P 54. Magnesium 72. TCLP-Pesticides ! 17. Solids, Total Dissolved 36. Sulfates 55. Manganese 73. TCLP-Herbicides 18. Solids. Total Volatile 37. Surfactants 56. Mercury 74. TCLP-Volatiles 19. Other: 38. UV254 57. Molybdenum 75. TCLP-BNA's U995U 58. Nickel

NYC-WTC_000025782