NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
wr SI CHLSTFR COUN I Y I ABC 335 QHES AND KE ; AicH
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2 Dana Road, Valhalla, New York 10595 ‘
11 lestchester County (914) 593-5575 Ps L/ln NYS-ELAP No. 10108
40
Sample Type (circle one): ' sp ■ e x 46*
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9041/22,
■
\ Form A-70 (rev. 1/96)
*** mGOLGtOUi ‘22 >2* ' ■ (Es > 0
(1. Potable) 1 3. Non-Potable Treated " Bottle #‘s9-.99. /4477242400275320
n NPotatiic 4. Other___________ Chain of Custody? '___ yes_____ no 95,
Time/Dale Collected:
Collected By -al
1-10O 3/61—
Agency Code:....
Comments:_____
PWS #:..... ... _...... Source ID: _ Type Descriptor
Collected From: Bill to 7
Location’s/Individual’s Name C ■ A --------- ------------ — Name/Company_ ___ _______
Street_5t_ s____ _e < „ _ . ’ ■ f "ni ■: — •—---------- f"....... u " ......... ..... ... .... T
Street
1 111 --===--=======——...... .....—- --- ——-
City/SUZipA/EAttkss__ KU.J. _
Identification of Source___
2. - City/StZip—--- Fax#
- , Phoneff
Collection Point&s 1... _L it (4 J CA, CH. BI?.... Check#:........ .. Amount?
BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTARLF/SOI ID ANAI YSFS
Labk_g Lab □ 7 ph/ 2.
(cicle tests) gircle 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) /
2. Coliform P/A (public supplies) 3.7 Volatile Aromatics (524) / 3. Acrolein & Acrylonitrile (624)
! 3. Coliform MPN (priv well, raw, stp) 4. Total Trhalomethane Potential (510) 4. Phthalates (606/8060)
| 4. Fecal Coliform (all samples) (5. Microextractables (504) -5. Organochlorine Pesticides (608/8080)
| 5. Microscopic 6. Pesticides (507) 6. PCB’s (Arochlors) (608/8080)
1Z.Pesticides/PCB screen (508) 7. Herbicides (SM-18/6640; 8151)
I 6. Macroscopic
IAPIr 8. PCB as Decachlorobiphenyl (508A)
29? Herbicides (515)
8.' Other Pesticides (SM-18/6630)
9. Petroleum Hydrocarbon Scan (310-13) .
Ger_ ___ ___ -10 Pesticides (525) 10. Glycols in Water i ' 2
Refrigerated?y e s _......... no (11? Carbamate Pesticides (531) 11. Acid Extractables (625/8270)
Li2:‘Glyphosate (5 4 7) 12. Base Neutral Extractables (625/8270)
Chionnated?: _____ yes.............. no < 213? Diquat (549) 13. GC/MS Unknown Scan .
14. Chlonnation Disinfection Byproducts (551) 14. Purgeable Halocarbons (DEF)
Free Chlorine Res:_________ mg/L 15. Haloacetic Acids (552) 15. Purgeable Aromatics (DEF)
16. Other Pesticides (SM-1 8/6630) 16 Pesticides (DEF) ' 3
1 Tutal Cn'onne Res: . .. 17. Petroleum/Hydrocarbon Scan (310-13) 17. PCB's (Arochlors) (DEF)
L D' £%2, /i/s
INORGANIC ANALYSES REQUESTED - Lab#:. ...
(circle tests) MN CsRoeeq
(39, Aluminum
__ 1. Color 20. Acidity / 59. Potassium
2. Turbidity//go 21. Alkalinity, as CaCOi 40.. Antimony 601 Selenium
3_H
i 4. Conductivity
22. Bromide
23. Bromate.’Chlorate/Chlorite
41J Arsenic
■ 42.Banum
61 Silver
62. Sodium
i 5 Corrosivity (temp:______ °C)
C ROD (5 day)
24. Chloride
25. Cyanide 44. Boron
43, Beryllium a 63. Thallium
\ 64. Vanadium
7 Soluble BOD (5 day) 26. Fluoride
27. Hardness, Total as CaCQ3 46. Calcium, as CaCOa
1(45) Cadmium m \65/Zinc______
CLP
8. Carbonaceous BOD (5 day)
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 G8 Susi volitil -
12. Total Organic Halides . 31. Nitrogen, Total Kjeldahl as N /50. Cobalt ns i "aheklizr 'Pt :5
) ’ 3. Solids, Percent (%)
A ggolids. Settleable
32. Oil and Grease
33 Phenol -
f 51: Copper
52.on-----
,53.Lead"
70. Disk Deliverables
TCLP
7-16. Solids. Total cat 36. Sulfates — 34. Phosphorus, Total as P
35. Phosphorus, Ortho as P
55.Manganese
54 Maqnasium
71. TCLP-Metals
72.TCLP. Pesticides
118. Solids.AEECASI
Total Volatile — 37.38.UV254m
17. Solids. Total Dissolved
19. Other:
Surfactants_ 56.Mercuryr
57. Molybdenum o
73. TCLP-Herbicides
74. TCLP-Volatiles '
75. TCLP-BNA’s
158/Nickelss
NYC-WTC_000025693
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