NYC 9/11 Public Portal Document
V'
' iri’
fill :ster
)v.com
i/Date Set;
ENVIRONMENTAL SERVICES.ISAMPLE SUB JSSjON FORM
WESTCHESTER COUNTY LABORATORIES ( 5b RbSEAl
2 Dana Road, Valhalla, New Yo'rk 10£
(914) 593-5575
to*
.
s
NYS-ELAP No. 10108
Sample Type (circle one):
^JsPdtable 3. Non Potable Treated Bottle rs: ill
2. Non PotableI 4. Other Chain of Custody'S I—iip«
Time/Date Colh Comments:
Collected By: Agency Code: PWS #;________ liirce ID: Type Descriptor:
Collected From: iGaa • Bill to:
Location’s/lndividual’s Name
S-'J; Name/Company
Street__________________________ Street_________
City/St/Zip _ _____________________ City/St/Zip______
Identification of Source r « I Phone#:_______ Fax#;
Collection Point MtPXU
CA,CH, Bl? A.',Check#: Amounts__ 1
BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS QRGANIC NONPOTABLE/SOLID ANALYSIS
Lab#:^_________________ Lab#: .
(circle tests) (circle tests)
1. Heterotrophic Plate 1 Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260)
Count (hemodialysis & all others) 2.5 Volatile Halocarbons (524) 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 Potential (510) 4. Phthalates (625/8270)
4. Fecal Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8081)
5. Microscopic ,6< Pesticides (507) . 6. PCB’s (Arochlors) (608/8081)
6 roscopic Vt* Pesticides/PCB screen (508) It-- Metho'prene (616)
7 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151)
8. Other: 91 Herbicides (515) 9. Pesticides (SMI8/6630)
’la Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13)
Refrigerate<;l? yes no
11. Carbamate Pesticides (531) 11. Glycols
Chlorinated:? 12. Glyphosate (547) 12. Acid Extractables (625/8270)
yes no
13. biquat (549) r' ia Base Neutral Extractables (625/8270)
Fruja Chlorine Res:. mg/L 14. Chlorination Disinfection Byproducts (551) I34)gc/MS Semivolatile Unknown Scan
Total Chlorine Res: mg/L 15. Haloacetic Acids (552) 15. Purgeable Halocarbons (QEF)
16. Pesticides (SMI8/6630) 16. Purgeable Aromatics (DEf)
pH ___________ 17. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB’s (DEF)
18. Other;__________________________ 18. Other;__________________________
INORGANIC ANALYSIS REQUESTED - Lab#; CO
(circle tests) -
1. Color * 20. Acidity 39. Aluminum 59. Potassium
2. Turbidity
3. pH
4. Conductivity
21. Alkalinity, as CaCOs
22. Bromide
23. Bromate/Chlorate/Chlorite
40. Antimony
41. Arsenic
42. Barium
60. Selenium
61. Silver
62. Sodium
KM
5. Corrosivity (temp:. ®C) 24. Chloride 43. Beryllium 63. Thallium
6. BOD (5 day) 25. Cyanide 44. Boron 64. Vanadium j
7. Soluble BOD (5 day) 26. Fluoride 45. Cadmium 65. Zinc ;
8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOa 46. Calcium, as CaCOs CLP
9. Chemical Oxygen 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-violatiles
12.’Total Organic Halides 31. Nitrogen, Total Kjeldahl as N 50. Cobalt 69. Pesticides/PCB’s
l^^olids. Percent (%) 32. Oil an Grease 51. Copper 70. Disk Deliverables
'^Hplids, Settleable . 33. Phenol 52. Iron
I^^olids, Suspended 34. Phosphorus Total as P 53.Lead I£kP
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_000071742
OCR can misread numbers and units. Confirm readings against the page image before using them.