NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
ster WESTCHESTER COUNTY LABORATORIES AND RESEARCH
com
2 Dana Road, Valhalla, New York 10595
(914) 593-5575
NYS-ELAP No. 10108
Time/Date Set: Form A-70 (rev.1/96)
ple Type (circle one):
1, Potable 3. Non Potable Treated Bottle ^s: 09* 'R^
2. Non Potable 4. Other __________ _____ Chain of Custody? eyes no
Time/Date Collected: - 77 - 0/ 0 %/ 5
Comments:
Collected By: 777 // Agency Code: _ Source ID: Type Descriptor:
Collected From: Bill to:
Location’s/individual’s Name. PSME Name/Company
Street____________________________________________ Street_______
City/St/ZIp_________ ___ ____________________________ _
Identification of Source __________ ___________ ___ Phone# ," ■ Fax#: 3 _ *** ...
2/76 PX57... _ •%
■ ; *.=t ‘*. - —
Collection Point _
CA,CH,B?2 Check#: v..... ; AmounisTE Th
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BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS Q ORGANIC NONPOTABLE/SOLID ANALYSIS
Lab#: '
(circle tests) (circle tests) 4 2 . O
1. Heterotrophic Plate
Count (hemodialysis & all others)
(12 Trihalomethanes (524)
(2. Volatile Halocarbons (524)
1. Purgeable Halocarbons (624/8260)
2. Purgeable Aromatics (624/8260) sA
8
(3 Volatile Aromatics (524) ****
2. Coliform P/A (public supplies) 3. Acrolein & Acrylonitrile (624)
3. Coliform MPN (privwell, raw,stp) 4. Total Trihalomethane Potential (510) 4. Phthalates (625/8270)
4. Fecal Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8081) J
5. Microscopic 6. Pesticides (507) 6. PCB’s (Arochlors) (608/8081) ' >
6. Macroscopic C Pesticides/PCB screen (508) 7. Methoprene (616)
7. 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151)
8. ten Herbicides (515) 9. Pesticides (SM18/6630) 7
Refrigerated? yes no 6 Pesticides (525)
11. Carbamate Pesticides (531) -
10. Petroleum Hydrocarbon Scan (310-13)—
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 (SM18/6630) 16. Purgeable Aromatics (DEF)
pH 17. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB’s (DEF) C - :
18. Other_______________________ 18. _ _____________________
INORGANIC ANALYSIS REQUESTED - Lab#:
(circle tests) KE7#LS
1. Color 20. Acidity 39. Aluminum 59. Potassium by.
2. Turbidity 21. Alkalinity, as CaCO3 40. Antimony 60. Selenium * *1
3. pH 22. Bromide 41. Arsenic 61. Silver 1
4. Conductivity 23. Bromate/Chlorate/Chlorite 42. Barium 62. Sodium ;
5. Corrosivity (temp:__ °C) 24. Chloride 43. Beryllium 63. Thallium *
6. BOD (5 day) 25. Cyanide 44. Boron 64. Vanadium
7. Soluble BOD (5 day) 26. Fluoride 45. Cadmium 65. Zinc
8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCO3 46. Calcium, as CaCOs CLP
9. Chemical Oxygen Demand 28. Nitrogen, Ammonia as N 47. Calcium, Ca+2 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
33. Phenol 52. Iron
14. Solids, Settleable 53.Lead
TCLP
Uolids, Suspended 34. Phosphorus Total as P
71 TCLP-Metals
10. Solids, Total 35. Phosphorus, Ortho as P 54 Magnesium 72. TCLP-Pesticides
17. Solids, Total Dissolved 36. Sulfates 55 Manganese
73. TCLP-Herbicldes
18. Solids, Total Volatile 37. Surfactants 56. Mercury
38. UV254 57 Molybdenum
74. TCLP-Volatiles
19. Other________________ 75.TCLP-BNAs
58. Nickel
Nl6
NYC-WTC_000025980
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