Environmental services sample submission form, Westchester County Lab

NYC 9/11 Public Portal Document

Si ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM

HI UlactehMlar County WESTCHESTER COUNTY LABORATORIES AND RESEARCH^ . 2 Dana Road, Valhalla, New York 10595 (914)593-5575 _____________ ; u 3'H ry iiay ' NYS-ELAP No. 10108 Form A-70 (rev. 1/96) Time/Date Set: Sample Type (circle one): o-fajSsiiot Pjontt i - x» ■ • 1. Potabig 3. Non-Potable Treated /'J Sy QtMOy - Z'N5h-Pmtable 4. Other________-r—s______ _ Chain of Custody?yes no * Time/Date Collected: . _ Comments: Collected BySuTT iLy-A I f** Agency Code: _ PWS #:________ .Source ID: Type Descriptor:. Collected From: Bill to: Location’s/lndividual’s Name f jC P _ Name/Company, Street 19 _ Street_________ Citv/St/ZiD I I ICt ki-t I < _ City/SVZip Identification of Source__ _ Phone#: ______ _Fax #: Collection Point C. iVT Cg FP- I I CA, CH, Bl?. Check#: Amounts.

BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLIO ANALYSES Lab#: _________________ __ Lab #:_ (circle tests) 1. Heterotrophic Plate Trihalomethanes (524)X,_ 1. Purgeable Halocarbons (624/8260) Volatile Halocarbons (524n^^''^ 2. Purgeable Aromatics (624/8260) ' Count (hemodialysis & all others) Volatile Aromatics (524) 7^ 3. Acrolein & Acrylonitrile (624) ' 2 Coliform (public supplies) 3. Coliform MPN (priv well, raw. stp) 4, Total Trihalomethane PWential (510) 4. Phthalates (606/8060) 4. Fecal Coliform (all samples) < Microextractables (504) 5. Organochlorine Pesticides (608/8OB0) ■S'; Microscopic 6_ Pesticides (507) 6. PCB’s (Arochlors) (608/8080) 2^Pesticides/PCB screen (508) 7. Herbicides (SM-18/6640; 8151) z 6. Macroscopic 7. API 8. PCB as Decachlorobiphenyl (508A) 8. Other Pesticides (SM-18/6630) 8. Other:______________ > SS? Herbicides (515) 9. Petroleum Hydrocarbon Sc^n (310^13) Pesticides (525) 10. Glycols in Water I Refrigerated? .yes. no Carbamate Pesticides (531) 11. Acid Extractables (625/827Q) Glyphosate (547) 12. Base Neutral Extractables (625/8270) no 35>Diquat (549) 13. GC/MS Unknown Scan K. Chiorinated?: yes. 14. Chlorination Disinfection Byproducts (551) 14. Purgeable Halocarbons (DS^ Free Chlorine Res:. mg/L 15. Haloacetic Acids (552) 15. Purgeable Aromatics (DEF)- 16. Other Pesticides (SM-18/6630) 16. Pesticides (DEF) Total Chlorine Res: mg/L 17. Petroleum/Hydrocarbon Scan (310-13) 17. PCB’s (Arochlors) (DEF)

jatL ///J INORGANIC ANALYSES REQUESTED - Lab#:___ (circle tests) 1. Color 2. Turbidity 20. Acidity 21. Alkalinity, as CaCOs Aluminum 40 Antimony A Potassium 60 Selenium 3. pH 22. Bromide 41. Arsenic 61. Silver 4. Conductivity 23. Bromate/Chlorate/Chlorite 42. Barium 62. Sodium 5. Corrosivity (temp: .°C) 24. Chloride VyBeryllium 63. Thallium 6. BOD (5 day) 25. Cyanide 43? Boron 64. Vanadium 7. Soluble BOD (5 day) 26. Fluoride Cadmium V^yZinc 8. Carbonaceous BOD (5 day) 27. Hardness. Total as C^iC^ 4^ Calcium, as CaCOa 9. Chemical Oxygen Demand 28. Nitrogen. Ammonia as N* Calcium. Ca*^ 66. Metals/CN 10. Dissolved Oxygen 29. Nitrogen. Nitrate as N “ Chromium. Total 67. Volatiles 11. Total Organic Carbon 30. Nitrogen. Nitrite as N 49. Chromium. Hexavalent 68. Semi-volatiles 12. Total Organic Halides ' 31. Nitrogen. Total Kjeldahl as N ✓S3 Cobalt 69. Pesticides/PCB’s 13. Solids, Percent (%) 32. Oil and Grease r 511 Copper 70. Disk Deliverables 14. Solids, Settleable 33. Phenol 521 Iron TCLP 15. Solids, Suspended 34. Phosphorus, Total as P 53.|Lead 71. TCLP-Metals 16. Solids, Total 35. Phosphorus. Ortho as P 54.lMagnesium 72. TCLP-Pesticides 17. Solids, Total Dissolved 36. Sulfates 55. Manganese 73. TCLP-Herbicides 18 Solids. Total Volatile 37 Surfactants 56. Mercury 74. TCLP-Volatiles 19. Other: K.) *, 38. UV254 57.Molybdenum 75. TCLP-BNA’s V58/Nickel

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