Sample submission form, Aug 2001

NYC 9/11 Public Portal Document

IB ENViRONNNTAY seAVICES sAMPr suoksSiov FOUM , 0 Hi |I wesrcHEsTgp.couNzYV-azopaToResanpreseaRcn / (o nosis" stle Type (circle one): ' 014)5935575 . 1 Potable 3. Non-Potable Treated 2 Non-Potable 4 Other_____ ________ 7 --------- Chain of Custody?-------- yes-------- no Time/Date CalartAdt 0100/09/42/01 Collected By oc c o /wkdveiL Agency Code:. Comments:______ ■■ PWS #: Source ID: Type Descriptor: Collected From: » _ _ Bin to: ' / i . 7 . I ' Location’s/Individual’s Name N C ' D r v _ Name/Company — .—.. : 0 ■ Street. ALkseD ____ t Street . . _ _ _ . ................. . _ City/SiZip. Valkall)./, 0<4s $ City/SV/Zip_ Identification of Source— . A Phone#:____ •.. —Fax# Collection Point.. 1V7 /% +G522 CA,CH,B1? Check#: . Amounts.

BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES Lab# Lab *____ ____________________ ____ (circle tests) (circle tests) AP1Ul . t 1. Heterotrophic Plate Trihalomethanes (524) ANN 0 1. Purgeable Halocarbons (624/8260) Count (hemodialysis & all others) Volatile Halocarbons (524) L‘ 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) Total Trihalomethane Potential (510) 4. Phthalates (606/8060) 4. Fecal Coliform (all samples) Microextractables (504) 5. Organochlorine Pesticides (608/8080) 5. Microscopic Pesticides (507) :6. . PCB's (Arochlors) (608/8080)

Macroscopic 6.or me Pesticides/PCB screen (508) 8. PCB as Decachlorobiphenyl (508A) 9.) Herbicides (515) 7: Herbicides (SM-18/6640; 8151) 8.1 Other Pesticides (SM-18/6630) 9. Petroleum Hydrocarbon Scan (310-13) ' ata jePesticides (525) J_ 10. Glycols in Water 11. Acid Extractables (625/8270) ( 11. Carbamate Pesticides (531) Reingerated? ....... yes....... . no 0

( 12. Glyphosate (547) 12. Base Neutral Extractables (625/8270) Chlorinated?:__ __ no 13. Diquat (549) H 13. GC/MS Unknown Scan 14. Chlorination Disinfection Byproducts (551) 14. Purgeable Halocarbons (DEF) ■free Chlorine Res: mg/L 15. Haloacetic Acids (552) 15. Purgeable Aromatics (DEF) 16. Other Pesticides (SM-18/6630) 16. Pesticides (DEF) Total Chlorine Res: mg/L 17. Petro^m/Hydro^rbon Scan (310-13) 17. PCB's (Arochlors) (DEF)

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INORGANIC ANALYSES REQUESTED - Lab#:. (circle tests) 1. Color ■ 20. Acidity 39. Aluminum ‘ 59. Potassium 2. Turbidity 21. Alkalinity, as CaCO3 40. Antimony ■ 4 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 CaCOa 46. Calcium, as CaCOa CLP 9. Chemical Oxygen Demand 28. Nitrogen, Ammonia as N 47. Calcium, Ca+2 66. 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-volatiles 12. Total Organic Halides 31. Nitrogen, Total Kjeldahl as N 50.Cobal 69.Pesticides/PCB‘s 13. Solids, Percent (%) . 32. Oil and Grease • 51. Copper 70. Disk Deliverables ; Solids. Settleable ; 33. Phenol • 52. Iron ‘ • olids. Suspended 3 34. Phosphorus, Total as P 53. Lead . ICLP , colds Total „.. 4 Phosphorun “ 54 Magnesium unni 254 ' esdenum 75. TCLP-BNA’s

NYC-WTC_000025783