NYC 9/11 Public Portal Document
. ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM r . <
er WESTCHESTER COUNTY LABORATORIES AND RESEARCH '
2 Dana Road, 1Va4)lha593l a,-5575
_9 New York
_ 10595/
NYSIAlNo 166
Time/Date Set:
jnnnniio 19
=
G .12 / ‘ /1K- (,7s ) -
Samplyp
" 1. Potable /
2 )
:3. Non Potable Treated
f* 553, 213 1, 4-30,9?
Bottle #‘s:_____ __ __ _ ________ 3,127, 8868-
2. Non Potable ' 4. Other Chain of Custody? . yes _..... no
Time/Date Collected: . 10^6 tc. / / ( tents
Collected By: /AleWAN Agency Code:___ PWS #_______ _ ___ Source ID: .Type Descriptor:
Collected From: Bill to:
. 220..,.
Location’s/Individual’s Name NY( " "As ro n 5 Name/Company..............
Street ' 1 I < -J ■ TAk
,08
_ _ Street, _...... .
City/SVZip _ Mae (.9 / . A _ A v / City/SVZip
. ..
Identification of Source ...____ ____ ___ : Phone#: ■ . . • Fax#
Collection Point_______________ __
CA.CH, Bl? _ Check#: Amounts
iiiiii
BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANAIYSS ORGANIC NONPOTABLE/SOLID ANALYSIS
Lab#: Lab#
(circle tests) /—
// 7,2/
/ / /U
(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) 3/ 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)
. Macroscopic (J Pesticides/PCB screen (508)
/APL_
8. Other:........ . . .............. ............. .
8. PCB as Decachlorobiphenyl (508A)
7f Methoprene (616)
8. Herbicides (EPA1978/8151)
9. Herbicides (515) 9. Pesticides (SM18/6630) '
io) Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13)
Refrigerated? . ..... . yes.. ..... no
Chlorinated:?____ yes____ no
11. Carbamate Pesticides (531)
12. Glyphosate (547)
11. Glycols 10/0101
12. Acid Extractables (625/8270)
13. Diquat (549) 13. Base Neutral Extractables (625/8270)
Free Chlorine Res:_ mg/L 14. Chlorination Disinfection Byproducts (551) (4/GC/MS Semivolatile Unknown Scan
15. Haloacetic Acids (552) 15. Purgeable Halocarbons (DEF)
Total Chlorine Res: _ ... _ mg/L
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)
1, Color of 20. .Acidity 39. Aluminum
62
59. Potassium
2. Turbidity 21. Alkalinity, as CaCOs 40. Antimony 60. Selenium
3, pH
4. Conductivity
22.Bromide.gMe
23. Bromate/Chlorate/Chlorite
41. Arsenic
42. Barium
61. Silver
62. Sodium
5. Corrosivity (temp:_____ °C) 24. Chloride Mdme
25. Cyanide
43. Beryllium
44. Boron
o i h.iiliun-
64. Vanadium
6.
7.
BOD (5 day)
Soluble BOD (5 day) uoride
26,i Fltadnes 45. Cadmium 165. Zinc ailC
* 13.1 (hd v)
:• r Mm C ■.'.!( ‘ Foman 2 N i ::
, iital . ( .* i!
N
46.Calcium, as CaCOs
47. Calcium, Ca+?
ICLPmaap
6r M tl/CN
10. Dissolved Oxygen
11. .Total Organic Carbon
‘ Nimaqen Nit* i । : N
Nilenig 1 Ni:- .*
48. Chromium, Total
49. Chromium, Hexavalent
11167. Volatiles
i:: viol Hor
1 Nalioger ededtS 50. Cobalt
12.'Total Organic Halides
— 32, 011 an Grease _ 52.Ion 51.Copper
pio cdeo/t cl "s
70. Disk Deliverables
13. Solids, Percent (%)
‘4. Solids, Settleable 33, Phenol
Phosphorus Total
16, Solids. Total_ 35.34.36, Phosphorus,
15. Solids, Suspended
OrthoasasP
Pt
53.Lead
54 Magnesium
TCLP
. 1 TC-Menla.
Sulfates_
17. Solids, Total Dissolved 137-Surfactants 55 Manganese
56. Mercury
:101 P Ptoml
,0 K : : j-H. . chlr :
18. Solids, Total Volatile
19. Otheresdl 38.UV254na 58. Nickel 57 Molybdenum
74. TCLP-Volatiles
i. p BNA-,
MR
NYC-WTC_000027703
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