NYC 9/11 Public Portal Document
2
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM / 3
ester
ovcom WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
(914) 593-5575
BY
. NYS-ELAP No. 10108
Time/Date Set: 1 Form A-70 (rev.1/96) -
Sample Type (circle one): cW3,t-(, .
(201,300,201. fe
(Potable 3. Non Potable Treated Bottle #‘s: Gs.ot,<uou ncol________
2. Non Potable 4. Other__ _____________________ Chain of Custody? yes no
Time/Date Collected: _ Q9/20/042- Comments:
Collected By. 9/19 roor HPadl Code: _ Source ID: .Type Descriptor
Collected From: Bill to:
Location’s/Individual’s Name _ _Bk. Name/Company _
Street____________ Street________
City/St/Zip _______ __ City/St/Zip _____ ________ .________ _ ________ —
Identification of Source Aep LA0* Phone#: ass________ __ Fax#: _______ ____
Collection Point _ 20 ES2 /. 20re■ " |-90
Z , / .eag CACH.BTT . checki*". ‘ Amounts q0
___ _____ ______ **y ' 5 12.80
BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS
Lab#:__________ __________ Lab#:______________________
(circle tests) (circle 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) 73. Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624)
3. Coliform MPN (priv well, raw, stp) 4. Total Trihalomethane Potential (510) 4. Phthalates (625/8270) .
4. Fecal Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8081)/
5. Microscopic 6. Pesticides (507) 6. PCB’s (Arochlors) (608/8081)
6. Macroscopic (“7.Pesticides/PCB screen (508) 7. Methoprene (616)
7. 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151)
8. ,9. Herbicides (515) 9. Pesticides (SM18/6630)
Refrigerated? yes no ( 10.) Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13)
-1. 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
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)
18. Other 18. Other________________________
INORGANIC ANALYSIS REQUESTED - Lab#:
(circle tests)
O_
1. Color 20. Acidity 39. Aluminum ..... - 59. Potassium
2. Turbidity 21. Alkalinity, as CaCOs 40. Antimony x 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 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 CaCOs 46. Calcium, as CaCOs is 0 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
14,Solids, Settleable 33. Phenol 52. Iron
TCLP
19lids, Suspended 34. Phosphorus Total as P 53 .Lead
71 TCLP-Metals
16. Solids, Total 35. Phosphorus, Ortho as P 54 Magnesium
72.TCLP-Pesticldes
17. Solids, Total Dissolved 36. Sulfates 55 Manganese
73. TCLP-Herblcldes
18. Solids, Total Volatile 37. Surfactants 56. Mercury
74. TCLP-Volatiles...
19. Other:_____ __________ 38. UV254 57 Molybdenum
75.TCLP-BNA’S
58. Nickel
_.... . s
NYC-WTC_000026264
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