NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
Vestcl isle WESTCHESTER COUNTY LABORATORIES AND RESEARCH
ieegovcom 2 Dana Road, Valhalla, New York 10595
(914) 593-5575
NYS-ELAP No. 10108
-0----------me/Date Set:
mf-/5M.6-H 0290. 6 7 43 758,083 -
Form A-70 (rev. 1/96)
Sample Type (circle one): c2‘/ ce7co c -/& _ 6/26 ,473. 79, //, 393- p
1. Potable 3. Non Potable Treated Bottle #‘s:.. 2 7/ 29 ___ ___ _ _.................. ..........2____ —..... ...... _ ..
2. Non Potable 4. Other Chain of Custody?yes___ no
Time/Date Collected; . /in /o ( Comments:
Collected By: DS Agency Code: PWS*........ .......... Source ID: _Type Descriptor:
3 _
Collected From: Bill to:
—
Location’s/Individual’s Name A/C A Name/Company
Street /? vr 74 C —le 0/, Street
City/St/Zip
1
//k/©A/002
*x F— 7 9 Cit/St/Zi-
Identification of Source
Collection Point de
P. 1
Phone*—------------ Fax#:_.
CA,CH, Bl?___ ______ Check#: Amounts
s1n11099-r499------=9---Aln=An9--------=--------------u-49--=-=9--A----I-----%==9-9PAI-49999=4=94===-=============================
BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS
Lab#:___________ _ -____________
(circle tests)
Lab#:_ .—£2949-2
(circle tests) /.( _ ‘ • —T.....
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. Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624)
3. Coliform MPN (privwoll, raw.stp) *4 Total Trihalomethane Potential (510) -4. Phthalates (625/8270)
4. Fecal Coliform (all samples) 5. Microextractables (504) 5. .Organochlorine Pesticides (608/8081)
6 Microscopic 6. Pesticides (507) 6. PCB’s (Arochlors) (608/8081)
/acroscopic 7.esticides/PCB screen (508) 7. Methoprene (616)
7. -8 PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151)
8. r 9. Herbicides (515) 9. Pesticides (SMI8/6630)
Refrigerated? ____yes____ no
/ 10.) Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13)
-T1. 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
_ mg/L 15. Haloacetic Acids (552) 15. Purgeable Halocarbons (DEF)
Total Chlorine Res:
16. Pesticides (SM18/6630) 16. Purgeable Aromatics (DEF)
pH ...... 17. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB’s (DEF) : —
18. Other:_______ ____ _ ___ _ _ . ..... _..... . 18. Other:______ _ _____________ _____ _
INORGANIC ANALYSIS REQUESTED - Lab#:
(circle tests) — yok 1774,
1. Color 20. Acidity 39 Aluminum T 1 59) Potassium
21, Alkalinity, as CaCOs 40. Antimony 60.' Selenium
2. Turbidity
3. pH 22. Bromide 41.Arsenic 61. Silver
4. Conductivity 23. Bromate/Chlorate/Chlorite i 42. Barium 62. Sodium
5. Corrosivity (temp:..... IC) 24. Chloride 43Beryllium 63. Thallium
6. BOD (5 day) 25. Cyanide 44. Boron 641 Vanadium
, 45%Cadmium
7. Soluble BOD (5 day) 26. Fluoride
27. Hardness, Total as CaCOs 46. Calcium, as CaCOs GLP
65/ Zinc
8. Carbonaceous BOD (5 day)
9. Chemical Oxygen Demand 08 Nin yon /r." : /4'A Calcium, Ca*2 66. Metals/CN
2) Nitro pt P (48/Chromium, Total
10. Dissolved Oxygen 5/ V. mf .
30. Nitrogen, Nitrite as N 49. Chromium, Hexavalent
11. Total Organic Carbon 68. Semi-violatiles
) 50.Cobalt
12. Total Organic Halides
-3 Solids, Percent (%)
31. Nitrogen, Total Kjeldahl as N
32. Oil an Grease 151.Copperdads 69. Pesticides/PCB’s
70. Disk Deliverables
. Solids, Settleable
Polids, Suspended
33. Phenol
34. Phosphorus Total as P
: 52.{Iron
53 -Lead
TCLP
54 Magnesium
71 TCLP-Metals
10Solids, Total 35. Phosphorus, Ortho as P
72. TOLP-Pesticides
17. Solids, Total Dissolved
18. Solids, Total Volatile
19. Other: _n?_s
37. Surfactants
36. Sulfates
38.UV254 57 Molybdenum
55 Manganese
56. Mercury
73. TCLP-Herbicides
74. TCLP-Volatiles
75. TCLP-BNA's
>58; Nickel
NYC-WTC_000026024
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