NYC 9/11 Public Portal Document
'V* ■ —T4riirrx4rj--*»-»-w^ . • — '•yr:y .
4.
ENVIRONMENTAL SERVICES.SAMPLE SUBMISSION FORM
HL
-f
WESTCHESTER COUNTY LABORATORIES AND RESEARCH
•L' , . 2 Dana Road. Valhalla, New York 10595.
lUMtchactertoxity NYS-ELAP No. 10108
Time/Date Set: ' V Form A-70 (rev. 1/96)
Sample Type (circle one):
Qy.Potable ■ /^;y3.-’Non-Potable Treated Bottle #’s:______ ■t
2. Non-Potable'''' '4. Other i » .___________ __■|^ Chain of Custody? .yes no
T, Comments:
Collected By:^^i^ZZZ i±^Agency Code:
---------- . PWS^:.-------------- liSource ID:. type Descriptor:
Bilito: ■
I ncatioriYs/indwiduars Name^*' «; ■ '111
;_____ 1 Name/Company_
Streetj£jf__SOZi<t3Z__ , .Street_____:.
City/St^;_______ ''. ;cjtwSt;^iD ; '
Identification of Sourceij»^ii:^i^•V 2___ vPhohei#:27___ ,Fax#f ■
Collection Poiritj • ’•Yle | CA, CH,'BPj.* ■ Check#: : Amount$ ■-
BACTERIOLOGICAL ANALYSES^": 5^ ;, ORGANIC NONPOTABLE/SOLID ANALYSES
La^jjaijweiWKS
1. Heterotro^fiW^lat^^:J^^^ '1’[^^Trihalomethanes;(524) 1. ‘Purgeable Halocarbdns(624/8260)''< ' •
Count (hemodialysi^&.allpthers)J /: 2. Purgeable Aromatics‘(624/8260)
2. Coliform P/A (f^blic supplies) ■St, Volatile Aromatics (524) 3.' Acrolein & Acrylonitrile (62^)'I.*' '. . '
3. Coliform MPN (priv well,"raw,*stpj •‘4.-/Totai Trihalomethane Potential (510) ■ ;' 4. Phthalates (606/8060);; A;;
4. Fecal Colifornri (all samples) '’; i 5. ; Micr6extractables''(504) - ' ' 5. Organochlorine Pesticides (608/8080)
5. ^croscopic ■ V '' • - . Pesticides (597),^ . . . 7 , '6. PCB’s (Arochlors) (608/8080) 'S
..e^’Mecroscopic ' ; -, ^<;Pesticides/PCB.sc^een (508) -Uf ■ < ; 7.. Herbicides (SM-18/6649; 8151) .
■8.i?PCB as Decachlor6biphenyr(508A) . .■S^^iieMaestj^es (SM-1^^ ■ -’•
7.AP!
8. Other:_________ ^Herbicides (515).' '.■^7' - • : 9. Petr6leutTiH>tJrocarbpri Scan (310-13) m
'^Pesticides (525) • • ' '^77'' ■ jo. Glycols in Water '
i';- ;r 4..
Refrigerated? jes i noypu 11. Carbamate Pesticides (531) ' , . . 11. Acid Extractables (625/8270)
'12. Glyphosate (547): ; .i- 1Z Base Neutral Extractabies (625/8270)
Chlorinated?: ves no 13."Diquat (549) •• GC/MS,Unknown Scan -w
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-18/6630) _ 16. Pesticides (DEF)
Total Chlorine Res: .mg/L 17. Petroleum/Hydrocarbon Scan (310-13) 17. PCB’s (Arochlors) (DEF)
7 i
pH
INORGANIC ANALYSES REQUESTED - Lab#:
(circle tests) i %
1. Color 20. Acidity 39. Aluminum 59. Potassium
2. Turbidity 21. Alkalinity, as CaCOa 40. Antimony 60. Selenium
3. pH 22. Bromide 41. Arsenic 61. Silver
4. Conductivity 23. Bromate/Chlorate/Chlorite 42. Barium 62. Sodium
5. Corrosivity (temp:_____ ®C) 24. Chloride 43. Beryllium 63. Thallium 1
6. BOD (5’ day) • 25. Cyanide 44. Boron 64. Vanadium 1
7. Soluble BOD (5 day)" '' 26. Fluoride 45. Cadmium 65. Zinc
8. Carbonaceouis BOD (5 day) 27. Hardness, Total as CaCOs 46. Calcium, as CaCOs CLP
9. Chemical Oxygen Demand 28. Nitrc^en, Ammonia as N 47. Calcium, Ca*’ 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-volatiles
12. Total Organic Halides 31. Nitrogen, Total Kjeldahl as N 50. Cobalt 69. Pesticides/PCB's
13. Solids, Percent (%) 32. Oil and Grease 51. Copper 70. Disk Deliverables
14. Solids, Settleable 33. Phenol 52. Iron ICLP
15. Solids, Suspended 34. Phosphorus. Total as P 53. Lead 71.TCLP-Metals
16. Solids, Total 35. Phosphorus, Ortho as P 54. Magnesium 72. TCLP-Pesticides
17. Solids, Total Dissolved 36. Sulfates ' 55. Manganese 73. TCLP-Herbicides
18. Solids. Total Volatile 37. Surfactants 56. Mercury 74. TCLP-Volatiles
19. Other:_______________ ' 38. UV254 57. Molybdenum 75. TCLP-BNA's
58. Nickel
NYC-WTC_000070211
OCR can misread numbers and units. Confirm readings against the page image before using them.