Environmental Services sample submission form, Sept 2001

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ster WESTCHESTER COUNTY LABORATORIES AND RESEARCH ►v.com 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): ^Potable 3. Non Potable Treated Bottle #’s: 2. Non Potable 4. Other Chain of Custody? Jk^es _ _ no Time/Date Collected: Comments: Collected By:. _ Agency Code: PWS #:______ Source ID: Type Descriptor: Collected From: Birt to: Location’s/lndividual’s Name. Z//4Z Niame/Company Street_____________ Street_______ City/St/Zip_________ City/St/Zip Identification of Source Phone#: Fax#: Collection Point CA.CH, Bl? Check#; Amounts.

BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANAIASIS ORGANIC NONPOTABLE/SOLID ANALYSIS Lab#:______________________ Lab#:iX <3 y (circle tests) (circle tests) 1. Heterotrophic Plate 1. Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260) I 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) f 4. Fecal Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8081) 5. Microscopic 6. Pesticides (507) 6. PCB’s (Arochlors) (608/8081) 6. Macroscopic Pesticides/PCB screen (508) 7. Methoprene (616) 7. API a PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151) 8. Other:____________________ 9. Herbicides (515) 9. Pesticides (SMI8/6630) Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13) •' Refrigerated?yes___ no 'S’ 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 (SMI8/6630) 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 59. Potassiuni . 2. Turbidity 21. Alkalinity, as CaCOa 40. Antimony 60. Selenium, 3. pH 22. Bromide 41. Arsenic 61. Silver i 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 CaCOa CLP 9. Chemical Oxygen Demand 28. Nitrogen, Ammonia as N 47. Calcium, Ca*^ 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.Cobalf 69.Pesticides/PCB's 13. Solids. Percent (%) 32. Oil an Grease 51. Copper 70. Disk Deliverables 14. Solids, Settleable 33. Phenol 52. Iron TQLP 15. Solids, Suspended 34. Phosphorus Total as P 53.Lead £i4 •M^nesium 71 .TCLP-Metals 16. Solids, Total 35. Phosphorus, Ortho as P 72.TCLP-Pesticides 17. Solids, Total Dissolved 36. Sulfates 55 Ma^qnese 73.TCLP-Herbicides 18. Solids, Total Volatile 37. Surfactants 56. Mercury ' 74. TCLP-Volatiles 19. Other:_________________ 38. UV254 57 Molybdenum 75.TCLP-BNA’S 58. Nickel

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