NYC 9/11 Public Portal Document
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ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
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WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
(914)593-5575
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NYS-LAP No.
B) 8
ime/Date Set:_____ .} A 7 (fi-V
Sample Type (circle one A ■ 2 v363 . 4f. , ,
(Awo0a4
III 1 Potable J 3. Non-Potable Treated Bottle #'s:_______ —_________
2; • Non-Potable 4. Other___ ____________ - Chain of Custody?_______ yes_____ no
Time/Date Collected:. J- ? 1 t ____________. Comments________________________ /
Collected By:? urr wD_________ Agency Code:_________ PWS #:________ Source ID: Type Descriptor:
- ' : p.
0 Location’s/Individual’s Name 4*0 15 r____ -______ ____
Street____ Pt i ssP < lk / . Street
City/SVZip )) ! s ■ s ___ City/StZip
t. Identification of Source................... ...... ........... .................................. Phone#:,_____ __ Fax#
Collection Point 1 I I f' ' ........ ......... CA, CH, Bl? ‘ Check#: Amounts
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BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES
Lab#- '
senA.Pmomoaiaammor*nmn II siillmnmm m ■■ rimiliiiin.... mimir"n ......... mruu..... I.—.,........ -
Lab # . _ _
(circle tests) . (circle tests)
1. Heterotrophic Plate 1. Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260)
Count (hemodialysis & all others) (2.) Volatile Halocarbons (524) 9 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 Potentia1(510) 4. Phthalates (606/8060)
4. Fecal Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8080)
6
n a 6. PCB’s (Arochlors) (608/8080)
1 5. Microscopic
6. Macroscopic
6
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Pesticides (507)
Pesticides/PCB screen (508) 57. . Herbicides (SM-18/6640; 8151)
( 7.APL 8. PCB as Decachlorobiphenyl (508A) J 8. Other Pesticides (SM-18/6630)
, Other:_______ _________ _ 9 Herbicides (515) - 9. Petroleum Hydrocarbon Scan (310-
0 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)
Chlorinated?:______ yes........... no 13. Diquat (549) d 3)GC/MS Unknown Scan
14. Chlorination Disinfection Byproducts (551) 14. Purgeable Halocarbons (DEF)
Free Chionne Res:. mg/L 15. Haloacetic Acids (552) 15. Purgeable Aromatics (DEF)
16 Other Pesticides (SM-18/6630) 16. Pesticides (DEF)
Total Chlorine Res:_ mg/L 17. Petroleum/Hydrocarbon Scan (310-13) 17. PCB’s (Arochlors) (DEF)
pH -........ 3 /
WONGANAYSSRoUTSID
(circle tests) _
1. Coror 20. Acidity
■::■ .•
39. Aluminum
■'
b
59. Potassium
. > : '
2. Turbidity 21. Alkalinity, as CaCO3 (40: Antimony • 60. Selenium
3pH 22. Bromide 41. Arsenic, _ 61. Silver
4. Conductivity 23. Bromate/Chlorate/Chlorite 42.. Barjum: 62. Sodium
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 CaCO3 46. Calcium, as CaCOa CLP
9. Chemical Oxygen Demand 28. Nitrogen, Ammonia as N 47. Calcium, Ca’? 6is. Mennt/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 6s. ■:.■> n vol es
12. Total Organic Halides 31. Nitrogen, Total Kjeldahl as N ( 50. Cobalt 6: i. Pstin-Ptl "
13. Solids, Percent (%) 32. Oil and Grease 51. Copper _70.Disk Deliverables
>4. Solids, Settleable 33. Phenol 52. Iron TCLP...........
15. Solids, Suspended
16. Solids, Total
34. Phosphorus. Total as P
35. Phosphorus, Ortho as P 54. Magnesium
53. Lead e /1. !l Me-t 11:'
2 00 Pest ides
17. Solids, Total Dissolved 36. Sulfates 55. Manganese 73. TCLP-Herbicides
18. Sohds, Total Volatile 37. Surfactants 56. Mercury 74. re P’-yeliriles
19. Other: z e - ■■ 38.UV254 (57) Molybdenum Z5. I Cl.P NA’s
58. Nickel
NYC-WTC_000027865
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