NYC 9/11 Public Portal Document
III
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
WESTCHESTER COUNTY LABORATORIES AND RFSLARC4
2 Dana Road, Valhalla, New York 10595
l=3st"la=g"y/Gont) 012(914)593-5575_ 1 ) NYS-ELAP No. 10108
ume/Date Set: ■ ; c 24 Form A-70 (rev. 1/96)
Gole Tyoe ■■ ■
GrER.eee10010
11 Potable a • Ne-- MMbos }rete i Bottle #’skGaA
2. Non-Potable • Of--i Chain of Custody?_____ yes no
Time/Date Collected: (4411/ ■ ->-01___ __
t unment
Collected __________________________ Agency Code: PWS #:____ Source ID: Type Descriptor:
Collected From R Bill to: /
Location’s Individual’s Name__ /IC__ Det__ Name/Company_____
Street______ L " -likal... .... ...
Street_......
Crty/St/Zip - ________ _
Crty/St/Zip
Identification of Source____ ___________________ __ Phone#:__ _______ Fax#:
Collection Pointy _eLb___ j GA, Cn, bi ___ Check#:_____ Amount?.
4*ti i 4 K*i ANALYS: " ONGANC foIA i ANAI *565 (ANiC NPNMOTAN i -ot IDANAYS s
Lab#:_______ _________ "LabW-e
(circle tests)
1. Heterotrophic Plate
—l(circleiests)daera
J 1, Trihalomethanes (524) i. Purgeable Halocarbons (624/8260)
Count (hemodialysis & all others) U2.2 Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260)
1 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 (510) 4. Phthalates (606/8060)
4. Fecal Coliform (all samples) ! 5. Microextractables (504) 5. Organochlorine Pesticides (608/8080) :
5. Microscopic . ‘ A 6. Pesticides (507) ; 6. PCB's (Arochlors) (608/8080)
6. Macroscopic ( 7. Pesticides/PCB screen (508) " 7 .Herbicides (SM-18/6640; 8151) 5
T.ARLa i 8. PCB as Decachlorobiphenyl (508A) 8. Other Pesticides (SM-18/6630)
3Ot h er: _ ___ _ _ ____ _____
( 10. Pesticides (525) n
A 9. Herbicides (515) ..9. Petroleum Hydrocarbon Scan (310-13)
. 10. Glycols in. Water
*
:
Refrigerated?:_ yes____ no
Chionnated?:___ yes_____ no
■1113.
12. DiGlqyuatphosate
(549)(547) v
“11. Carbamate Pesticides (531)
Gdm
.11. Acid Extractables (625/8270)
12. Base Neutral Extractables (625/8270)
13. GC/MS Unknown Scan
14. Chlorination Disinfection Byproducts (551)i 14. Purgeable Halocarbons (DEF)
Free Chlorine Res:_ ... mg/L 15. Haloacet.c Acids (552) 15. Purgeable,Aromatics (DEF)
16. Other Pesticides (SM-18/6630) 16. Pesticides (DEF)
Total Chlorine Res: _ _g/L 17. Petroleum/Hydrocarbon Scan (310-13) 17. PCB's (Arochlors) (DEF)
Mxilane
PH___ aa"
i'.-./ ar ANAI v . s 14 cn Si D ;. N
(circle tests) == ======5============
1652 YO—
-1. Colona
2. Tuibidity
20. Acidity
,21. Alkalinity, as CaCO3
/391 Aluminum
40 Antimony
/*—*59. Potassium .
• ho. Selenium
3.pHGa
4. Conductivity
5. Corrosivity (temp:____ _OC)
22. Bromide
23. Bromate/Chlorate/Chiorite
.24. Chloride 3 Arsenic
Barium
Beryllium
_61 Silver
2/62 Sodium
63/ Thallium
V
6. BOD (5 day) 25. Cyanide 44. Boron 64i Vanadium
7. Soluble BOD (5 day) 26. Fluoride (45 Cadmium (65. Zinc .
8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOa , 46. Calcium, as CaCOa
(47 Calcium, Ca+2
CLP
9. Chemical Oxygen Demand 28. Nitrogen, Ammonia as N 66. Metals/CN
10. Dissolved Oxygen
11. Total Organic Carbon
29. Nitrogen, Nitrate as N
30. Nitrogen, Nitrite as N
(48. Chromium, Total
49. Chromium, Hexavalent
67. Volatiles "
68. Semi-volatiles
12. Total Organic Halides 31. Nitrogen, Total Kjeldahl as N (50 Cobalt 69. Pesticides/PCB's
13. Solids, Percent (%)
14 Solids, Settleable
!
33. Phenol “ be Lead
32. Oil and Grease
34.Phosphorus.IotalasPl 5352 Iron
51 Copper
TCLP_ns
70. Disk Deliverables
t
1 35. Phosphorus, Ortho as Ps 54 Magnesium
.71. TCLP-Metals
72. TCLP-Pesticides
—36. Sulfates id Manganese
18. Sol i d s. Tot al Vol a
17. Solids, Total Dissolved
19.Other.bnsa 38.1IV254 ti l e d -.37, Surfactants — . 56.Mercuryed
■ 57 Molybdenum a
55
74.TCLP-Volatiles
73. TCLP-Herbicides
7 IPINA
, adksdashalndaz Saz
1.58. Nickel Ce
evsnakssdaatd Eat
NYC-WTC_000026515
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