Environmental Services Sample Submission Form, Sept 2001

NYC 9/11 Public Portal Document

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

S^pleType (circle one): /^/Potable 3. Non Potable Treated Bottle #’s; 2. Non Potable 4. Other ______________ ________ Chain of Custody? yes no Time/Date Collected: >4^^ 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 I Identification of Source Phone#:_______ Fax#: Collection Point CA.CH. Bl? Check#: Amounts.

( BACTERIOLOGICAL ANALYSIS ORGANIC^T^^^^rSI^ ORGANIC NONPOTABLE/SOLID ANALYSIS Lab#:______________________ (circle, tests) (circle tests) 1. Heterotrophic Plate 1. Trihalomethanes (524) 1, Purgeable Halocarbons (624/8260) ' , Count (hemodialysis & all others) 2. Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260) 2jfcbltform 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) 5. Organochlorine Pesticides (608/8081) 5.,Microscopic 6. Pesticides (507) 6. PCB’s (Arochlore) (608/8081) 6: Macroscopic Pesticides/PCB screen (508) 7. Methoprene (616) i 7. API X 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151) ■fl 8. Other:_________ __________ 9. Herbicides (515) 9. Pesticides (SMI 8/6630) Refrigerated? __ yes__ _ no Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13). 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 (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#: co (circle tests) i 1, Color 20. Aridity 39, Aluminum 59. Potassium 2. Turbidity 21. Alkalinity, as CaCOs 40. Antimony 60. Seleniu^ 3. pH 22. Bromide 41. Arsenic 61. Silver j 4. Conductivity 23. Bromate/Chlorate/Chlorite 42. Barium 62. Sodiurr) 5. Corrosivity (temp:. .®C) 24. Chloride 43. Beryllium 63. Thalliu^ 6. BOD (5 day) 25. Cyanide 44. Boron 64. Vanad^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 TCLP 15. Solids, Suspended 34. Phosphorus Total as P 53.Lead 71 .TCLP-Metals 16. Solids, Total 35. Phosphorus, Ortho as P 54 Magnesium 72.TCLP-Pesticides 17. Solids, Total Dissaved 36. Sulfates 55 Manganese 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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