Sample submission form, Sep 2001

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ster 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 *s: __________________ 2. Non Potable 4. Other__________ Chain of Custody? no Time/Date Collected: 0-/6-0/ 0800 Comments: Collected By: Agency Code: PWS#:___________ Source ID: .Type Descriptor Collected From: Bill to: Location’s/individual’s Name 4/6L1/z ASG2 Name/Company Street____________ Street _______ CIty/St/Zip_________ Cly/stZp_ Identification of Source Phonek apapeps . " 208-2,** Fax# ' ■ ■ •.. —T "

Collection Point 5/72 CACH,B25. e99P**7e Check#: Amounts t

BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSS "Y**T ORGANIC NONPOTABLE/SOLID ANALYSIS Lab#:____________________ Lab*_____ <0 " (circle tests) (circle tests) C C ? f f . 1. Heterotrophic Plate Q 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) S 3. Coliform MPN (priv well, raw, stp) 4. Total Trihalomethane Potential (510) 4. Phthalates (625/8270) r- : 4. Fecal Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8081) TJ 5. Microscopic 6. Pesticides (507) 6. PCB’s (Arochlors) (608/8081) 6. Macroscopic 7. Pesticldes/PCB screen (508) 7. Methoprene (616) - 7. 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151) 8.’ rer 9. Herbicides (515) 9. Pesticides (SM18/6630) Refrigerated? yes no 10. Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13) 5 11. 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) 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_______________:______ __ •**d • - *s

INORGANIC ANALYSIS REQUESTED - Lab#: © - (circle tests) 1. Color 20. Acidity 39. Aluminum 59. Potassium n 2. Turbidity 21. Alkalinity, as CaCOs 40. Antimony 60. Selenium 2 3. pH 22. Bromide 41.Arsenic* • 61. Silver f 97 4. Conductivity 23. Bromate/Chlorate/Chlorite 42. Barium 62. Sodium i 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 lids, Settleable 33. Phenol 52. Iron TCLP lids, Suspended 34. Phosphorus Total as P 53.Lead 71 .TCLP-Metals lids, Total 35. Phosphorus, Ortho as P 54 Magnesium 17. Solids, Total Dissolved 36. Sulfates 55 Manganese 72. TCLP-Pesticides 73.TCLP-Herblcldes 18. Solids, Total Volatile 37. Surfactants 56. Mercury 38. UV254 57 Molybdenum 74. TCLP-Volatiles 19. Other________________ 75.TCLP-BNAs 58. Nickel 107 no anmrrki©lhadu. ........ skiz NYC-WTC_000025977