NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
ster WESTCHESTER COUNTY LABORATORIES AND RESEARCH
iv.com
2 Dana Road, Valhalla, New York 10595
(914) 593-5575
NYS-ELAPNo. 10108
TDate Set: X 9m A-70 (rev.1/96)
Sample Type (circle one): /SS0 ----- 6w—49 Q.. E2 ----_.
79..
fry
1. Potable 3. Non Potable Treated Bottle #s:. eass , os8 o
Chain of Custody?__ I yes | no ~3
2. Non Potable 4. Other
Time/Date Collected: / Poj U : / P* Comments:
Collected By. v s Vos 6 - -V Agency Code: PWS#:______ Source ID: .Type Descriptor:
Collected From: Bill to:
Location’s/Individual’s Name 2v Name/Company
Street________________ Street_______
City/St/Zip_____________ CIty/St/Zip____
Identification of Source___1 Phone#: Fax#:
Collection Point 5550 De# CA,CH, Bl? 2Z Check#: Amounts.
-2/00% 5ey
BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPQTABLE/SOLID ANALYSIS
Lab#:____________________ Lab#:__________ .
(circle tests) (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) 8
3. Coliform MPN (priv well, raw, stp) 4. Total Trihalomethane Potential .(510) 4. Phthalates (625/8270) —
4. Fecal Coliform (ail samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/808183
5. Microscopic 6. Pesticides (507) 6. PCB’s (Arochlors) (608/8081) 1
6.@groscopic ( Pesticides/PCB screen (508) 7. Methoprene (616) P
7.77 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151)
8. Other__________________ 9 Herbicides (515) 9. Pesticides (SM18/6630) >
(0 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) CD
J
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:. *1 8. Other: -
INORGANIC ANALYSIS REQUESTED - Lab#:
(circle tests)
14 4 C
CO
1. Color 20. Acidity 39. Aluminum slum -<
2. Turbidity 21. Alkalinity, as CaCOs 40. Antimony 60. Selenium
3. pH
4. Conductivity
5. Corrosivity (temp:__
6. BOD (5 day) '
7. Soluble BOD (5 day)
°C)
22. Bromide
23. Bromate/Chlorate/Chlorite
24. Chloride
25. Cyanide
26. Fluoride
41. Arsenic
42. Barium
43. Beryllium
44. Boron
45. Cadmium
61. Silver
62. Sodium
63. Thallium
64. Vanadium
65. Zine
1
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 TCLP
54 Magnesium
71 .TCLP-Metals
35. Phosphorus, Ortho as P
16. Solids, Total
36. Sulfates 55 Manganese 72. TCLP-Pesticides
17. Solids, Total Dissolved 73.TCLP-Herbicides
18. Solids, Total Volatile 37. Surfactants 56. Mercury
19. Other: ________________ 38. UV254 57 Molyodenum 74. TCLP-Volatiles
75.TCLP-BNA’S
58. Nickel
&-sbitottkd s. -..
NYC-WTC_000027808
OCR can misread numbers and units. Confirm readings against the page image before using them.