NYC 9/11 Public Portal Document
09
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
ster WESTCHESTER COUNTY LABORATORIES AND RESEARCH
vcom 2 Dana Road, Valhalla, New York 10595
(914) 593-5575
nfp ate Set: r i
NYS-ELAP No. 10108
Form A-70 (rev. 1/96)
Sample Type (circle one):
—p.- "K
> ' .i •2 • )
“ 7.. .
1. Potable 3. Non Potable Treated Bottle #‘s:
X5)9
*i
i :
G’/
2. Non Potable 4. Other _______________ Chain of Custody? yes no
Time/Date Collected: _ 10111/2001 0827 Comments:
Collected By: - Dossoule Agency Code: PWS# Source ID: .Type Descriptor:
Collected From: Bill to:
Location’s/individual’s Name Name/Company
Street_________________ Street_________
City/St/Zip______________ City/St/Zip
Identification of Source 2__2 beP# ; Phone#: Fax#:
-67.0
Collection Point
."7
—ICA,CH,BrTF— Check#:
.14
Amounts.
BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOND ANALYSIS
Lab#:____________ r .5. Lab:------- —— 1.
(circle tests) A? sorcle tests) .
1. Heterotrophic Plate 1.Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260)
/2. Volatile Halocarbons (524) 7
Count (hemodialysis & all others) 2. Purgeable Aromatics (624/8260) y"?
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) P
4. Fecal Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8081)
5. Microscopic 6. Pesticides (507) 4 6. PCB’s (Arochlors) (608/8081) 59
6.@roscopic (7 Pesticides/PCB screen (508) 7. Methoprene (616)
7.W 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151)
8. Other____________________ 9. Herbicides (515) 9. Pesticides (SM18/6630)
Refrigerated? yes no
(10.. Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13)
TL Carbamate Pesticides (531) 11. Glycols 8.3
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 14. Chlorination Disinfection Byproducts (551) 44.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.__________________________
•========H=-=
INORGANIC ANALYSIS REQUESTED - Lab#:
(circle tests)
1. Color 20. Acidity
JMS+0 39. Aluminum
2 59. Potassium
(4l
f::
2. Turbidity 21. Alkalinity, as CaCOs 40. Antimony 60. Selenium
3. pH 22. Bromide 41. Arsenic 61. Silver i
4. Conductivity 23. Bromate/Chlorate/Chlorite 42. Barium 62. Sodium i
• 5. Corrosivity (temp: °C) 24. Chloride
25. Cyanide
43. Beryllium
44. Boron
63. Thallium
64. Vanadium
6. BOD (5 day) *
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
Colids, Settleable 33. Phenol 52. Iron
15. Solids, Suspended 34. Phosphorus Total as P 53.Lead IGLE
71 .TCLP-Metals
16. Solids, Total 35. Phosphorus, Ortho as P 54 Magnesium
72.TCLP-Pesticldes
17. Solids, Total Dissolved 36. Sulfates 55 Manganese
73. TCLP-Herbicides
18. Solids, Total Volatile 37. Surfactants 56. Mercury
57 Molybdenum 74. TCLP-Volatiles
19. Other_________________ 38. UV254
75.TCLP-BNA’s
58. Nickel
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NYC-WTC_000027806
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