NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
ster Westchester county laboratories and research
A com 2 Dana Road, Valhalla, New York 10595
(914) 593-5575
Ame/Date Set: QC St Exka 6ottlDAd/~ NYS-ELAP No. 10108
Form A-70 (rev.1/96)
Sample Type (circle one):
1, Potable 3. Non Potable Treated Bottle #‘s: 0 i 4 0 L
2. Non Potable 4. Other ___ _______________________ Chain of Custody? yes no
Time/Date Collected: _ / 20 ( 10: 4^ a 4 Comments:
Collected By: 8.6etsrk Agency Code: PWS#:_______ Source ID: Type Descriptor:
Collected From: Bill to:
Location’s/Individual’s Name Byoxy Name/Company
Street________________ Street________
City/St/Zip____________ City/St/ZIp
pYCBeP LAB#
Identification of Source Phone#:______ Fax#:
Collection Point 14350 /
CA,CH, Bl? Check#: Amounts.
BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS
Lab#:_____ Lab#:____________________
T
(circle tests) (circle tests)
1. Heterotrophic Plate 1. Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260)
Count (hemodialysis & all others)
2. Coliform P/A (public supplies)
3. Coliform MPN (priv well, raw, stp)
8 Volatile Halocarbons (524)
Volatile Aromatics (524)
4. Total Trihalomethane Potential (510)
2. Purgeable Aromatics (624/8260)
3. Acrolein & Acrylonitrile (624)
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 79Pesticides/PCB screen (508) 7. Methoprene (616)
____________________ • s. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151)
9. Herbicides (515) 9. Pesticides (SM18/6630)
10) Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13)
Refrigerated? yes no -11 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 714. Chlorination Disinfection Byproducts (551) 14. GC/MS Semivolatile Unknown Scan
Haloacetic Acids (552) ,
Total Chlorine Res: -mol,v 54 115.
16. Pesticides (SM18/6630)
15. Purgeable Halocarbons (DEF)
16. Purgeable Aromatics (DEF)
pH . 7 $ 117. Petroleum/HydrocarbonScan (310-13) 17. Pesticides/PCB's (DEF)
m=
10o9999p*p**/99*=,/$=2=78T* ■' 1000999n929==9==127 —92-P2*--
19!!9 ! =?5-?-99!?ng219 915555=====-"
18.. Other:
INORGANIC ANALYSIS REQUESTED - Lab#:
(circle tests) .
A 2 6 ——
1. Color 4. 20. Acidity 39. Aluminum 59. Potassium
2. Turbidity 21. Alkalinity, as CaCOa 40. Antimony 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 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
24.Solids, Settleable 33. Phenol 52. Iron
TCLP
(Solids, Suspended 34. Phosphorus Total as P 53.Lead 71 TCLP-Metals
16. Solids, Total 35. Phosphorus, Ortho as P 54 Magnesium
55 Manganese 72.TCLP-Pesticides
17. Solids, Total Dissolved 36. Sulfates
56. Mercury 73. TCLP-Herblcldes
18. Solids, Total Volatile 37. Surfactants
19. Other________________ 38. UV254 57 Molybdenum 74. TCLP-Volatiles
75.TCLP-BNAS
58. Nickel
NYC-WTC_000026354
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