Environmental Services Sample Submission Form, Sept 2001

NYC 9/11 Public Portal Document

11 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); ^J^otable 3. Non Potable Treated Bottle #’s: 2. Non Potable 4. Other __ _________________ ______ Chain of Custody? yes no Time/Date Collected: _ Comments: Collected By: Agency Code: PWS #;________ Source ID: Type Descriptor: Collected From: , Bill to: Location’s/lndividual's Name Name/Company Street__________________ __________________________ Street_______ _ City/St/Zip_________________________________________ City/St/Zip Identification of Source_______________________________ Phone#:_______ Fax#: Collection Point _ _______________________ CA.CH, Bl? Check#; Amounts.

BACTERIOLOGICAL ANALYSIS ORGANIC ^TA^E ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS Lab#: ______________ __ (circle tests) (circle tests) “ s 1. Heterotrophic Plate 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) 4- 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) 5. Microscopic 6. Pesticides (507) 6. PCB’s (Arochlors) (608/8081) 6. Macroscopic ^Pesticides/PCB screen (508) 7. Methoprene (616) 7. API 8. PCBras Decachlorobiphenyl (508A) 8. Herbicides (EPAI 978/8151) ’U 8. Other: __ ______________ 9. Herbicides (515) 9. Pesticides (SM18/6630) (f^ Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13) 77 Refrigerated?yes no f; 11 Carbamate Pesticides (531) 11. Glycols Chlorinated;? yes no 12. Glyphosate (547) 12. Acid Extractables (625/8270) i 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) I . 1. Color 20. /'cidity 39. Aluminum 59. Potassium 2. Turbidity 21. Alkalinity, as CaCOs 40. Antimony 60. Seleniurn 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. Vanadii)m 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*^ 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 14. Solids, Settleable 33. Phenol 52. Iron TCL P 15. Solids, Suspended 34. Phosphorus Total as P 53.Lead 71 TCLP-Metals 16. Solids, Total 35. Phosphorus, Ortho as P 54 Magnesium 36. Sulfates 72. TCLP-Pesticides 17. Solids, Total Dissolved 55 Manganese 73.TCLP-Herbicides 18. Solids, Total Volatile 37. Surfactants 56. Mercury 38. UV254 57 Molybdenum 74. TCLP-Volatiles 19. Other;______________ ___ 75.TCLP-BNA’s 58. Nickel

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