Sample submission form, Sep 2001

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ster com WESTCHESTER COUNTY LABORATORIES AND RESEARCH 15 2 Dana Road, Valhalla, New York 10595 (914) 593-5575 NYS-ELAP No. 10108 Time/Date Set: Form A-70 (rev.1/96)

Sal tie type (circle one): Bottle ,a 28073 7 Potable 2. Non Potable 3. Non Potable Treated 4. Other__________ Chain of Custody? —yes no Time/Date Collected: 9-/60/ 0833 Comments: Collected By: Agency Code: PWS#:________ Source ID: .Type Descriptor. Collected From: Bill to: Location’s/ndividual’s Name Name/Company Street____________ Street_________ _ CIty/St/ZIp _ Identification of Source ■ Phone#: ": 4t ri__ _____ **”*opref* -)*at . . $ • • T Fax#: • t * * 5 ‘i .** * " Collection Point S/fe VKSg CACHBM?! Checkit - Amounts " 5 •_ -============================?===============-===!======= BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS Tr ORGANIC NONPOTABLE/SOLID ANALYSIS Lab#:____________________ Lab#: 600 ----- -L (circle tests) 0. (circle tests) $5? 1. Heterotrophic Plate 1. Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260) 3 Count (hemodialysis & all others) 2. Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260) rR 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) 6. Organochlorine Pesticides (608/8081)' 5. Microscopic . 6. Pesticides (507) 6. PCB’s (Arochlors) (608/8081) 6. Macroscopic $ (7 Pesticides/PCB screen (508) ; 7. Methoprene (616) 7. 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151) 3 ‘*? 8. r: 9. Herbicides (515) 9. Pesticides (SM18/6630) * yes no (0 Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13) ci Refrigerated? 11. Carbamate Pesticides (531) 11. Glycols Chlorinated:? yes no 12. Glyphosate (547) 12. Add 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) 18. Other_______________________ 17. Pesticides/PCB’s (DEF) 18. Other_____________ —e- - vebeeva INORGANIC ANALYSIS REQUESTED - Lab#: e (circle tests) 59. Potassium^ L 1. Color 20. Acidity 39. Aluminum 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 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-vlolatiles 12. Total Organic Halides 31. Nitrogen, Total Kjeldahl as N SO.Cobalt 69. Pesticides/PCB’s 13. Solids, Percent (%) 32. Oil an Grease 51. Copper 70. Disk Deliverables 14.Solids, Settleable 33. Phenol 52. Iron TCLP 10lids, Suspended 34. Phosphorus Total as P 53.Lead 71 .TCLP-Metals 54 Magnesium 16. Solids, Total 17. Solids, Total Dissolved 35. Phosphorus, Ortho as P 36. Sulfates 55 Manganese 72. TCLP-Pesticides 73. TCLP-Herblcides 18. Solids, Total Volatile 37. Surfactants 56. Mercury 57 Molybdenum 74. TCLP-Volatiles 19. Other________________ 38. UV254 58.Nickel------ 75.TCLP-BNA8 me uunat .i 44 NYC-WTC_000025978