NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ; / AT
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lli
iilestchester County
WESTCHESTER COUNTY I ASORATOSICS ANO SE.ARCH
2 Dana Road, Valhalla, New York 10595
(914) 593-5575
2
/ .
NYS-EI AP No 10108
Form A-70 (revia) .
ime/Date Set:____________________________
C-o2S K 4: Gho, 71 00 , -200.7
Sample Type (circle one):
Peli r t, 1002 , 5 mGuty*iek, 7 ■
1. Potable ) 3. Non-Potable Treated Bottle #‘s._
2 Non-Potable 4. Other; Chain of Custody?yes no
i Time/Date Collected:_____ I - o _ _____ i
■ -
comments: ' .
..............................................................
i
i Collected ________________ i______ Agency Code—--------- PWS #_____________Source ID:____ —Type Descriptor:
Collected From: . .. ' Bill to: ’ *
d
Location‘s/Individual‘s Name P • y C .. lli.... .. .. ............ - Name/Company______ ______________________________ ■
(
Street___? i 1.) 0 A' (MYr h/7 Street ________ .
; City/SZip_Oa/—UA/0y City/SVZip.
Identification of Source • •_____ __________ __ __ _______ Phone#:
Collection Point 0i2 ........................ - CA,CH,Bl?
-Fax#
Check#: Amount$ .
______________ _____________________
BACTERIOLOGICAL ANALYSES ORGANIC..POTABLE
... . ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES ‘
Lab# :=-=
(circle tests)
Lab #:___ _______ ___________
(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)
37 Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624)
2. Coliform P/A (public supplies)
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 6. Pesticides (507) 6. PCB’s (Arochlors) (608/8080)
,7. Herbicides (SM-18/6640; 8151)
6. Macroscopic - .
7.AP
. Other:____________________ _ 9. Herbicides (515)
18 Other Pesticides (SM-18/6630)
9. Petroleum Hydrocarbon Scan (310-
40) Pesticides (525) 10. Glycols in Water
Refrigerated?_____ yes____ _ no 11. Carbamate Pesticides (531) 11. Acid Extractables (625/8270)
12. Glyphosate (547) 12, Base Neutral Extractables (625/8270)
Chlorinated7:___ __ yes... .... __.no 13. Diquat (549) (13! GC/MS Unknown Scan
14. Chlorination Disinfection Byproducts (551) 14. Purgeable Halocarbons (DEF)
Free Chlorine Res:_________ mg/L . 15. Haloacetic Acids (552) 15. Purgeable Aromatics (DEF)
16. Other Pesticides (SM-1 8/6630) 16. Pesticides (DEF)
_ /i
Total Cnonne Res: mq/L 17. Petroleum/Hydrocarbon Scan (310-13) 17. PCB’s (Arochlors) (DEF)
PH. 8643
,sk
14 j— 3 f‘rf 6
INORGANIC ANALYSES REQUESTED - Lab#_ 4 • 5 . .....
(circle tests) eWt
1. Color 20. Acidity 39. Aluminum 59. Potassium
2. T urbidity 21. Alkalinity, as CaCOa .40. Antimony 60. Selenium
3 pH 22. Bromide 41. Arsenic;, 61. Siiver
4. Conductivity 23. Bromate/Chlorate/Chlorite 42. Barium, d, So-lim
5. Corrosivity (temp:__ .. C) 24. Chloride 43. Beryllium 63. Thallium
6. BOD (5 day) 25. Cyanide 44. Boron 64. 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 CLP_
9. Chemical Oxygen Demand 28. Nitrogen, Ammonia as N 47. Calcium, Ca*2 tit Mot :AN
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 6if. Semi val iif :
12. Total Organic Halides 31. Nitrogen, Total Kjeldahl as N 50, Cobalt i' j. P=a le PCE’s
13. Solids, Percent (%)
’ 4. Solids, Settleable
32. Oil and Grease
33. Phenol
51. ICopper
52, ron — 7 70. Disk Deliverables
TCLP
15. Solids, Suspended 34. Phosphorus. Total as P -53, Lead n /.1ct Velal
70 1 0 s ‘ \ - tie
16. Solids, Total 35. Phosphorus, Ortho as P 54. Magnesium
i
17. Solids, Total Dissolved t
18. Solids. Total Volatile
36. Sulfates
37. Surfactants
55. Manganese
50, Mercury
3 I i i * He i widet
iA. (LP-Vuiatigr
i
19. Other: ...' ; . ___ 38.UV254 57: Molybdenum /$ TCP ENA'S
58. Nickel
NYC-WTC_000027864
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