NYC 9/11 Public Portal Document
ENVIRONMENTAL SÉRVICES SAMPLE SUBMISSION FORMi.
WESTCHESTER COUNTY LABORATORIES AND RESEARCH!
2 DầnaRoad,•Välhälläy Nëw:York 10595
ester County
(914)$935575
Time/Date Set:
Sample Type (circle one):
Potable
3. Non-Potable Treated
Non-Potable:
4.
Other
Time/Date Collected:-
11.35-01
0922
Collected Bý: NEWANN
Agency Code:L
Collected From:
Location's/Individual's Name.
ATE DECDENIrO
Street
City/SV/Zip.
WAHAHA, VY: lUStE
Identification of Source.
Collection Point_
"7!17
¿ Böftle'#'s:
Chain of Custody?
Comments:
PW$ #:
Bill to:
Name/Company.
Street
City/SV/Zip.
Phone#:
CA, CH. BI?
BACTERIOLOGICAL ANALYSES
ORGANIC POTABLE ANALYSES
Lab#:
(circle tesis)
1. Heterotröphic Plate
Count (hemodialysis & all others)
2. Coliform PIA (public supplies)
3. Coliform MPN (priv, well, raw, stp)
4. Fecal Coliform (all samples)
5. Microscopic
6. Macroscopic /
y.APi
•8. Other::
Refrigerated?
yes.
no
Chiornated?:
Free Chlorine Rés:
yes
mg/L
Total Chlorine Res: _
:mg/L
Lab#:
(circle lests)
Trihalomethanes (524)
Volatilé Halocarbons (524)
Volatile Aromatics (524)
4:
•Total Trihalomethane Potential (510)
15:
Microextractables (504)
Pésticides (507)
7:
Pesticides/PCB screen (508)
8.
9.
PCB as Decachlorobiphếny| (508A)
Herbicides (515).
'10: Pesticides (525):
11: Carbamate Pesticides (531).
•12: Glyphosate (547):
13: Diquat (549)J
.14: Chlorination Disinfection Byproducts (551)
15. Haloacetic Acids (552)
16. Other Pesticides (SM-18/6630)
17. Petroleum/Hydrocarbon Scan (310-13)
pH
INORGANIC ANALYSES REQUESTED - Lab#:
(circle tests)
1. Color
2.
Turbidity
3.
pH
.4.
Conductivity
5.
Corrosivity (temp:_
°C)
6.
BOD (5 day)
7.
Soluble BOD (5 day)
8.
Carbonaceous BOD, (5 day).
9.
Chemical Oxygen Demand
10. Dissolved Oxygen.
11. Total Organic Carbon,
12. Total Organic Halides
13. Solids; Percent (%)!
)4: Solids, Séttléablé
f15. Solids. Suspended*
11.6. Solids‹Tötäl
'1,7. Solids: Totãl Dissolved"
!18
:Sòlids; Ț.õłal,Völătile
$19. Other:
37 Sürfactants:
3841IV254
20. Acidity
21. Alkalinity, as CaÇO3
22. Bromide
23. Bromate/Chlorate/Chlorite
24. Chloride
25. Cyanide
26. Fluoride
27. Hardness; Total as CaCOs.
28. Nitrogen, Ammonia as N..
29.:Nitrogen; Nitrate as N:
30.Nitrogen, Nitrite asN.
31. Nitrogen; Total Kjeldahl as'N
.32nQiland Grease
334Phènol
34: PhosphorusATotal as P
35: Phosphorus, Orho as P
39₽
Aluminum
'40. Antimony
41: Àrsenic
42. Barium
43. Beryllium
44. Boron
45: Cadmium
46. Calcium, as CaCO3.
47 Calcium Gatmi
48: Chromium, Total.
49. Chromium, Hexavälent
'50:'Cobalt
51: Copper
52, Iron:
53! Leady
54-Magneșiumi
55. Mänganese
56! Mercury/
"57: Molybdenum
58! Nickel!
NYC-WTC_000070920
NYS-ELAP No.10108
Form A-70 (rev. 1/96)
iyes.no
Source ID::
{Type" Descriptor:
Fax#:
Check#:
Amount$
ORGANIC NONPOTABLE/SOLID ANALYSES
1. Purgeable Halocarbons (624/8260)
2.
Purgeable Aromatics (624/8260)
3.
Acrolein & Acrylonitrile (624)
4.
Phthalates (606/8060)
Organochlorine Pesticides (608/8080)
6.
PCB's. (Arochlors) (608/8080)
7., Herbicides (SM-18/6640; 8151)
Other Pesticides (SM-18/6630)
9.?. Petrölëum Hydrocarbon Scan (310-13)5
10. Glycols in Water.
11 . Acid Extractables:(625/8270)
12; Base Neutral Extractables (625/8270)
GC/MS Unknown.Scan.
4. Purgeable Halocarbons (DEF)
15. Purgeable Aromátics (DEF).
16. Pesticides (DEF)
17. PCB's (Arochlors) (DEF)
Xuit)
tüca?
59.Potassiom, Aw
60. Selenium
61. Silver
62 Södium
*63 Thallium
istai
64-Vanadium
65.-Zinc
CLP?E
66. Metals/CNJ
67 Volatiles:
68. Semi-volatiles
,69. Pesticides/P,CB's
701Disk Deliverables
TCLP
71: TCLP Mètals,
72:TCLP-Pesticides:,
73!TCLP Herbicides;
$74.ȚCLP-Volätilés
75:ICLP-BNAS)
OCR can misread numbers and units. Confirm readings against the page image before using them.