NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
Vooldliste r VESTCHESTFR COUNTY LABORATONIES AND RESEARCH
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_NSELAPNo.101
fmne : 1 1 ** lnabMLeanCForm.A-70.(rev.1/96, —
aac-aloK=&2R180M/12030,03*264514
$* plc Type (circle one):
( Potable) Nog i . 0 li- .* "!
2. Non Potable 4. Other e Chain of Custody? yes no
Time/Date Collected: _ ---- 4 41 qnemmggots:
Collected By: _nec Agency Code: PWS *__ _ __Source ID: .Type Descriptor:
Culecto From:
JekeM
Bill to: ?
Location’s/individual’s Name 44 — Name/Company_
Street___4 C Street___________
City/St/Zip _ (g City/St/Zip
Identification of Source________ Phone#:______ _ Fax#:__
Collection Point _ (_ | _P
CA.CH, Bl? _ Check#: Amounts____
FAC FLRN ri GGICAl ANALYSIS QKGANC [alt. AMAl Y— I RGAANONPOTAEL t/St ID ANAI YS5
Lab#:_________ __ -____________
(circle tests)
1. Heterotrophic Plate
Lab#:___
(circle tests)
1. Trihalomethanes (524)
20 1. Purgeable Halocarbons (624/8260)
Count (hemodialysis & all others) 72.olatile Halocarbons (524) 2. Purgeable Aromatics (624/8260)
2. Coliform PZA (public supplies) • 3. Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624)
3. Coliform MPN. (privwell, raw, stp) ( 94r"Total Trihalomethane Potential (510)
4. Phthalates (625/8270)
4. Fecal Coliform (all samples) ‘5. Microextractables (504) 5. Organochlorine Pesticides (608/8081) o
5. Microscopic 6. Pesticides (507) 6. PCB's (Arochlors) (608/8081)
6. Macroscopic (7Pesticides/PCB screen (508) 7. Methoprene (616)
-8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151)
er: 9.*Herbicides (515) 9. Pesticides (SMI8/6630) > /
TOPesticides (525) 10. Petroleum Hydrocarbon Scan (310-13) '
Refrigerated? _ ___yes
Chlorinated:? yes
no
no
**11 Carbamate Pesticides (531)
12. Glyphosate (547)
11. Glycols pe eem
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: __ ____________ _ ___________
INORCANIC ANALYSIS REQUESTED ■ ■ .
(circle tests)
1. Color
2. Turbidity
20. Acidity
21. Alkalinity, as CaCOs
38lAluminum
40. Antimony 5
yihl :59.|Potassium
160. Selenium
3. pH 22. Bromide 41. Arsenic 61. Silver 2
4. Conductivity
5. Corrosivity (temp:______ °C)
23. Bromate/Chlorate/Chlorite
24. Chloride
42. Barium aaa
; 43 Beryllium
62. Sodium
63. Thallium ./14
25. Cyanide 44. Boron 64. Vanadium V l t ■
6. BOD (5 day)
7. Soluble BOD (5 day) 26. Fluoride 45.Cadmium 65/ Zinc i
8. Carbonaceous BOD (5 day) 27. Hardness. Total as CaCOs
28. Nitrogen, Ammonia as N
46. Calcium, as CaCOa
47\Calcium, Ca42
CLP_
9. Chemical Oxygen Demand 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
31. Nitrogen, Total Kjeldahl as N 50 Cobalt
12. Total Organic Halides
13. Solids, Percent (%)
14.Solids, Settleable
11 an Grease alld
3332,, 0Phenol
51 Copper
521 Iron
69. Pesticides/PCB’s
. { i • Ptaroaoo .
53|Lead TCLP
Colids, Suspended 3 L Ph r l.ii:: ■ I ■ lx 1 r. ■
I n I! i ' Motal;
" : . : 1!
35. Phosphorus, Ortho as P 54 Magnesium
53 Caakoa 55 Manganese
2/ 0PPeuk
15756.MolMercury
ybdenum.v
17. Solids, Total Dissolved
18. Other
19. Solids, ngn
Total Volatile 7 Surfariaas
A UY*1
/3 ICLP 1 lebicos
/ I CLP Volanles
.'5. CANA
1 58. Nickel
NYC-WTC_000026404
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