Sample submission form, Sep 2001

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ster >v.com WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914) 593-5575 NYS-ELAP No. 10108 Time/Date Set: Form A-70 (rev.1/96)

Sample Type (circle one): (1/Potable 3. Non Potable Treated Bottle #*8:. 2/72 2. Non Potable 4. Other_______________________ Chain of Custody? 'es no Time/Date Collected: —2/0/0%00 _ Comments: ' Collected By:______ __ A Agency Code: _ _ Source ID: .Type Descriptor: Collected From: Bill to: Location’s/ndividual’s Name A/CLl/ewRsv2 Name/Company _ Street______________ _ _________________________ Street City/St/Zip________________ '_____________ _ _ ■A citymap _ __ • .. 7 llee

-"Iha Identification of Source ___________ _ ______________ Collection Point _ -$/7E7X3 — CAcHsioh, ’s : »ei ■ ■ 4**6 ‘*i ■ Check#: Fax# Amounts i -

- * ‘==*.0 - । ■' . . . ... 185’!‘,! — BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS.: 5 ORGANIC NONPOTABLE/SOLID ANALYSIS Lab#:____________________ ... (circle tests) 1. Heterotrophic Plate 225824 . 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) 3. Acrolein & Acrylonitrile (624) 3. Coliform MPN (priv well, raw, stp) 4. Total Trihalomethane Potential (510) 4. Phthalates (625/8270) 4. Fecal Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8081) s 5. Microscopic 6. Macroscopic 6. (7. Pesticides (507) Pesticides/PCB screen (508) 6. PCB’s (Arochlors) (608/8081) 7. Methoprene (616) 76 __________________________ 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151)

2 Herbicides (515) 9. Pesticides (SM18/6630) Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13) Refrigerated? yes no Carbamate Pesticides (531) **11. Glycols > Chlorinated:? yes no 12. Glyphosate (547) 12. Acid Extractables (625/8270) 13. Diquat (549) 13. Base Neutral Extractables (625/8270) Free Chlorine Res:. mg/L 14. Chlorination Disinfection Byproducts (551)I 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. Pestlcldes/PCB's (DEF) 18. Other__________________ ________; 18. Other _________ ;____________

INORGANIC ANALYSIS REQUESTED - Lab#: (circle tests) 1. Color 20. Acidity 39. Aluminum 59. Potassium i 2. Turbidity 21. Alkalinity, as CaCOs 40. Antimony 60. Selenium co 3. pH 22. Bromide 23. Bromate/Chlorate/Chlorite 41. Arsenic 42. Barium 61. Silver (( 7 o 62. Sodium- ‘ 4. Conductivity 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 CaCOs 46. Calcium, as CaCOs 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-violatiles 12. Total Organic Halides 31. Nitrogen, Total Kjeldahl as N 50. Cobalt 69. Pestlcldes/PCB’s 13. Solids, Percent (%) 32. Oil an Grease 51. Copper 70. Disk Deliverables 14Solids, Settleable 33. Phenol 52. Iron TCLP 1lids, Suspended 34. Phosphorus Total as P 53 .Lead 71 .TCLP-Metals 16. Solids, Total 35. Phosphorus, Ortho as P 54 Magnesium 72.TCLP-Pesticldes 17. Solids, Total Dissolved 36. Sulfates 55 Manganese 73.TCLP-Herblcides 18. Solids, Total Volatile 37. Surfactants 56. Mercury 38. UV254 57 Molybdenum 74. TCLP-Volatiles 19. Other_________________ 75.TCLP-BNAs 58. Nickel dsdoakatati NYC-WTC_000025975