NYC 9/11 Public Portal Document
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ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
■ WESTCHESTER COUNTY LARMAATORIES AND RESEARCH
| 2 Dana Road. Valhalla, New York 10595 ‘
I
ik*6k lxii* Gxot
914593-5575 NYS-ELAPNo. 10108
ne/Date Set: Form A-70 (rev. 1/96)
■pie Type (circle one): ror(e (4. 760e ** ! $7,7242.6852.7786
1. Potable 3. Non-Potable Tre&ted
iAI57PA-296,4/9,G-Ss.cP-,soc+6
Botte # s:______ (_____________ .________________________ _ __ (__
2. Non-Potable
alolorii
4. Other______________
Time/Date Collected:__ (424
Collected By:L____ __ __ Agency Code:___
Chain of Custody?
Comments:,
PWS #:____
yes no
___ Source ID:________Type Descriptor;___
Collected From:
_tppa*eetedmtee
Bill to: d
Location's/Individual's Name__ — ____ ___ _ -.... . Name/Company__
street • ----- -........
EGev ; , Akom9/2 Street...........
City/St/Zip... __ ___________ ____ _ Crty/St/Zip_........
Identification of Source_ Phone#: Fax #:__ __ :_____
Collection Point___ LC_ CA. CH, BI?.......... Check#:Amounts.
BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES QNGANC NONMOIABL :/$01[ ANALYSES
Lab*:___ ___ _ ______ _ _______ Lab #__ ;
(circle tests) (circle tests).
11. Count
Heterotrophic Plate 2000
(hemodialysis & all others)
1.
(2.
Trihalomethanes (524)
Volatile Halocarbons (524)
1.
2.
Purgeable Halocarbons (624/8260)
Purgeable Aromatics (624/8260)
2 Coliform P/A (public supplies) 3/ Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624)
- 3. Coliform MPN (priv well, raw, stp) 4. Total Trihalomethane Potential (51 0) 4. Phthalates (606/8060) . ■ 2
| 4. F»x al Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8080)*
| 5. Microscopic 6. Pesticides (507) :6, PCB’s (Arochlors) (608/8080) . 3
j 6. Macroscopic ' 7 Pesticides/PCB screen (508) 77Herbicides (SM-18/6640; 8151)
zAPI 8. PCB as Decachlorobiphenyl (508A) 8 Other Pesticides (SM-18/6630)
10. Pesticides (525)
9! !Petroleum Hydrocarbon Scan (310-13)
Other:
igerated?____ yes____ no
9. Herbicides (515)
11. Carbamate Pesticides (531)
a 10. Glycols in Water
11. Acid Extractables (625/8270)
2
12. Glyphosate (547) 12. Base Neutral Extractables (625/8270) -
Chlorinated7:_____ _________no 13. Diquat (549) 13. GC/MS Unknown Scan
14. Chlonnation Disinfection Byproducts (551) 14. Purgeable Halocarbons (DEF)
15. Haloacetic Acids (552) 15. Purgeable Aromatics (DEF)
Free Chionne Res:
Total Chlorine Res:
___ _
_mg/L
16. Other Pesticides (SM-18/6630)
17. Petroleum/Hydrocarbon Scan (310-13)
-16. Pesticides (DEF) Mgmda
17. RGB’s (Arochlors) (DEF)
L pH _ _
Ab: A*Alva S HQUS! D . .
(circle tests) 000 AWet
j 1. Color e 20. Acidity Aluminum 59 Potassium 4 ,
i 2. Turbidity 21. Alkalinity, as CaCO; Antimony 60 Selenium £ Y/
3pH
j 4. Conductivity
22. Bromide
23. B ro mat e/Ch lor a t e/C h lor it e
41 Arsenic
4,21 Barium
61 Silver
62 Sodium
4 )
1
I 5 Corrosivity (temp: °C) 24, Chloride 43. Beryllium 63 Thallium 1
C BOD (5 day) 25. Cyanide 44. Boron 64 Vanadium
7. Soluble BOD (5 day)
8. Carbonaceous BOD (5 day)
26. Fluonde
27. Hardness, Total as CaCO3
{ 45. Cadmium
,
46. Calcium, as CaCOa
65. Zinc__ ____
CLP ~ ~
47. Calcium, Ca*" ■ •
9. Chemical Oxygen Demand
10. Dissolved Oxygen
11. Total Organic Carbon
28. Nitrogen, Ammonia as N
.29. Nitrogen, Nitrate as N
30. Nitrogen, Nitrite as N
4 48/Chromium, Total
'49. Chromium, Hexavalent
■ 67. Volatiles Jus,
66. Metals/CN
Ci Geamni vol 1 • .
12. Total Organic Halides 31. Nitrogen, Total Kjeldahl as N j 60 Cobalt 69. Pesticides/PCB's
13. Solids. Percent (%)
1 Solids, Settleable 33. Phenol gemngnee -53.52,Iron
32. Oil and Grease
Lead
j 51/Copper / !), 6 *, in L
TCLP
sh
w
r. q*pvri
54.Maanesium
3-1 PAut ph r. -. 1d-[‘ /I. H i IMaal
1118 Solids, Total Volatile A.2.2 36.37.Surtactantss
Sulfates 55, Manganese I 73.TCLP-Herbicides
35. Phosphorus, Ortho as P 7 i i P P, " •
17. Solids, Total Dissolved
19 Other ./ 38.UV254
56.Merourv.Mal 57. Molybdenum " / !Cl P V :!.<!;!<■
75.TCLP-BNA's3
58. Nickel
_saansasalacad
NYC-WTC_000026327
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