Sample submission form, Sep 2001

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM 1

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late Set: WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914) 593-5575 09 NYS-ELAP No. 10108 Form A-70 (rev.1/96)

pie Type (circle one): Boulays- 773 .1. otable 3. Non Potable Treated 2. Non Potable 4. Other______________________ Chain of Custody? _ yes no Time/Date Collected:; 9-/50/ 233/ Comments: Collected By: "E Agency Code: _ Source ID: Type Descriptor Collected From: Bill to: Location’s/Individual’s Name /Z21ze Asi Name/Company____; Street________________ Street City/St/Zip_____________ ‘ Clty/StZip__ Identification of Source . _ ___________ ____ .Phon* r Motrckogsrogte ' : ■ . Fax#: Collection Point _ . S/762XS8 ': <0 i " * frescmsrerumpoynes 7*.* -+.adktomyttt* -------------------- - Checki Amounts jwiin. , . ■ —-------omupppoeptuanongeng *** ■ * " •• • . ■■ .pp*e BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS *‘t ORGANIC NONPOTABLE/SOUD ANALYSIS , 5 - Lab#:____________________ Lab#:----- , AcC. (circle tests) (circle tests) CC6 1 1. Heterotrophic Plate 1. Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260) Count (hemodialysis & all others) 2. Purgeable Aromatics (624/8260) Po) 2. Volatile Halocarbons (524) 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) Pts 4. Fecal Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/80812. 5. Microscopic 6. Pesticides (507) 6. PCB’s (Arochlors) (608/8081)' _ 6. Macroscopic ( Pesticides/PCB screen (508) 7. Methoprene (616) 7 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151) J 9. Herbicides (515) 9. Pesticides (SM18/6630) 25 Refrigerated? Chlorinated:? yes yes no no QI Pesticides (525) Carbamate Pesticides (531) 12. Glyphosate (547) 10. Petroleum Hydrocarbon Scan (310-13) 11. Glycols 12. Acid Extractables (625/8270) ,

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________ _______________ 18. Other:___________ ;

INORGANIC ANALYSIS REQUESTED - Lab#: (circle tests) 1. Color 20. Acidity 39. Aluminum VlBa, 59. Potassium 2. Turbidity 21. Alkalinity, as CaCOs 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 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. Pesticides/PCB’s 13. Solids, Percent (%) 32. Oil an Grease 51. Copper 70. Disk Deliverables 14Solids, Settleable 33. Phenol 52. Iron TELE Colids, Suspended 34. Phosphorus Total as P 53.Lead 71 .TCLP-Metals 16. Solids, Total 35. Phosphorus, Ortho as P 54 Magnesium 36. Sulfates 55 Manganese 72.TCLP-Pesticides 17. Solids, Total Dissolved 73. TCLP-Herbicides 37. Surfactants 56. Mercury 18. Solids, Total Volatile 19. Other:________________ 38. UV254 57 Molybdenum 74. TCLP-Volatiles 75.TCLP-BNA’S 58. Nickel _z 4 = NYC-WTC_000025976