Environmental services sample submission form, Westchester County Lab

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM 1, ) bv.com WESTCHESTER COUNTY LABORATORIES AND RESEARCH ’ > ' 2 Dana Road, Valhalla, New York 10595 . , 1^ (914)593-5575 * ('^1 NYS-ELAeNori0108 Tme/Date Set:

Sample .Type (circle one); . Potablg, ^ 3. Non Potable Treated Bottle r>: 2mon Potable 4. Other Chain of Custody?^;^^ yes no

Tlme/Date Collected: Comments: Collected By: tufeci tilciQ AAA-OC Agency Code: PWS#; Source ID: Type Descriptor: Collected From: -so t Bill to: / Location's/lndividuars Name /\J Name/Company street , Street ________ City/St/Zip______________r/—h___ tr_____ _____ — City/St/Zip Identification of Source \l^ / ho 114 ^7_______ Phone#; Fax#; Collection Point. jlfiZLJSd=L_____________ I CA,CH, Bl? Check#: Amounts

BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOUD ANALYSIS Lab#;_______________ ■ Lab#:___________ ____________ (circle tests) (circle tests) 1. Heterotrophic Plate (vTrihalomethanes (524) 1. Purgeable Halocarbons (624/8260) Count (hemodiatysis & all others) ® Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260) 2. Coliform P/A (public supplies) Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624) 3. Coliform MPN (priv well, raw, stp) A Total Trihalomethane Potential (510) 4. Phthalates (625/8270) 4. Fecal Coliform (all samples) Microextractables (504) 5. Organochlorine Pesticides (608/8081) r 5. Microscopic 6., Pesticides (507) 6. PCB’s (Arochlors) (608/8081) 6. Macroscopic Pesticides/PCB screen (508) 7. Methoprene (616) 7. API 8. PCB as Oecachlorobiphenyl (508A) 8. Herbicides (EPAI 978/8151) 8. Other;____________________ ^Herbicides (515) 9. Pesticides (SM18/6630) yes___ no Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13) Refrigerated? Carbamate Pesticides (531) 11. Glycols Chlorinated;? yes no '^Glyphosate (547) 12. Acid Extractables (625/8270) ^Diquat (549) 13. Base Neutral Extractables (625/8270) Free Chlorine Res;. mg/L iX? 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 IZ Petroleum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB’s (DEF) @Other 5Sb t 18. Other:__________________________ ••S ANALYSIS REQUESTED - Lab#; II INORGANIC (circle tests) 1. Color 20. Aridity 39.]Aluminum *5^ Potassium 2. Turbidity 21. Alkalinity, as CaCOa 4oJAntimony 60. Selenium 3. pH 22. Bromide 41/Arsenic ei.jSilver iT 4. Conductivity 23. Bromate/Chiorate/Chlorite 4^ Barium 62. Sodium 5. Corrosivity (temp:. .“C) 24. Chloride \«. B^ryflium 63. Thallium 6. BOD (5 day) 25. Cyanide 44. Boron 64.1 Vc Vanadium 7. Soluble BOD (5 day) 26. Fluoride (^pCadmium \ s/ziinc 8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOs 4^Calcium, as CaCOa CLP 28. Nitrogen, Ammonia as N ^^teakium, CaY^ 9. Chemical Oxygen Demand 66.Metals/CN 10. Dissolved Oxygen 29^ Nitrogen, Nitrate as N /A^Chromium, Total 67. Volatiles 11. Total Organic Carbon 30. Nitrogen, Nitrite as N Chromium, Hexavalent 68. Semi-violatiles 12. total Organic Halides . 31. Nitrogen, Total Kjeldahl as N /S&JCobatt ' 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 \4agnesium 72.TCLP-Pesticides 17. Solids, Total Dissolved 36. Sulfates 55 i4anganese 73.TCLP-Herbicides 18. Solids, Total Volatile 37. Surfactants 56.Mercury 74. TCLP-Volatiles 19. Other:_________________ 38. UV254 57 Vldybdenum 58/Nickel 75.TCLP-BNA's

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