NYC 9/11 Public Portal Document
»
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
UtalSSO«ity WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
(914)593-5575 . NYS-ELAP No 10108
Time/Date Set:______________________________
Sample Type (circle one):
f-fat, r 7
Potable 3. Non-Potable Troatad 1_________
2. Non-Potable 4. Other_______ ,___________ Chain of Custody? .yes no
Time/Date Oollaetad: ______ Comments:_____
Collected By:.____________________ Agency Code:. PWS #:. : . Source ID: Type Descriptor:
Colfected From: Gill to:
Location's/lndividuars Name Name/Company
Street_____________________________________ Street
City/SVZip______________ /___________________ Citv/St/Zip
IdentificationofSource—
Phgne#:_ Fax#:.
( C/L CH. Bl? Check#: Amounts.
Collection Point
BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES
Lab#:______________ _ Lab'#:______________
(circle tests) (drcte tests) : ’ ' ;'.
1. Heterotrophic Plate Trihalomethanes{524) ' 1.; Purgeable Halocarbons (624/8260). i ' '
Count (hemodialysis & all others) / Volatile Halocarbons (524) 2. Purgeable Ar6tTiatics(624/B260) :
2. Coliform P/A (public supplies) * .Jr Volatile Arorhatics (524) ; -3. ’ Acrolein & Acrylonitrile (624)
3. Coliform MPN (priv well, raw, stp) 4. Total Trihalomethane Potential (510) ■ 4. Phthalates (606/8060) ft
4. Fecal Coliform (ail samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8080) "
5. Microscopic 6. Pesticides (507) : '6. PCB's (Arochlors) (608/8080) ’t
6. Macroscopic Pesticides/PCB screen (508) - 7. Herbicides (SM-18/6640; 8151),
7. ap: 8. PCB as Decachlorobiphenyl (508A) ? 8. Other Pesticides (SM-18/6630) i:
8. Other:___________________ 9^ Herbicides (515) 9. Petroleum Hydrocarbon Scan (310-13)
@ Pesticides (525) 10. Glycols in Water
Refrigerated? yes no 11. Carbamate Pesticides (531) 11. Acid Extractables (625/8270)
12. Glyphosate (547) ia Base Neutral Extractables (625/8270) ■
Chlorinated?: yes no 13. Diquat (549) (^GC/MSUnknown Scan
14. Chlorination Disinfection Byproducts (551)I 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)
pH
INORGANIC ANALYSES REQUESTED - Lab#:
(circle tests)
^5^ I
1. Color 20. Acidity 39. Aluminum 59. Potassiup
2. T urbidity 21. Alkalinity, as CaCOa 40. Antimony 60. Seleniurri
3. pH 22. Bromide 41. Arsenic 61. Silver i
4. Conductivity 23. Bromate/Chlorate/Chlorite 42. Barium 62. Sodium,
5. Corrosivity (temp: .’C) 24. Chloride 43. Beryllium 63. Thalliurn
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 £LE
9. Chemical Oxygon Demand 28. Nitrogen, 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 TCLP
15. Solids. Suspended 34. Phosphorus. Total as P 53. Lead 71. TCLP-Motals
16. Solids, Total 35. Phosphorus. Ortho as P 54. Magnesium 72. TCLP-Pesticidos
17. Solids, Total Dissolved 36. Sulfates - 55. Manganese 73. TCLP-Horbicidos
18 Solids. Total Volatile 37. Surfactants 56. Mercury 74. TCLP-Volatilos
19. Other:_____________ 38. IIV254 57. Molybdenum 75. TCLP-BNA'S
58. Nickel
NYC-WTC_000070572
OCR can misread numbers and units. Confirm readings against the page image before using them.