NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
•WWni WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
NYS-ELAP No. 10108
le/Date Set: Form A-70 (rev, 1/96)
Sample Jype (circle one); €1 f'*'*’/ z.r,F'v
gg Pottle’ 3. Non Potable Treated Bottle #'s; ( . Y C h; AL &S 5Z.,
“2?T3on Potable 4. Other ______ Chain of Custody? yes no
Time/Date Collected; b' '' Comments: _____
Collected By: )h Agency Code;' Source ID; Type Descriptor;
Collected From: Bill to;
Location’s/lndividual’s Name Name/Company ___
Street ■' i g.. |il8it/itiaS|gjglSggl8
City/St/Zip T , r sBiM8|gi|g||gg
Identification of Source- Phone#: _______ Fax#;^
Collection Point g.g
CA.CH, Bl? Check#;: Amounts
BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS
(circle tests)
1. Heterotrophic Plate 1. Trihalomethanes (524)Bi||®|||i|| 1. Purgeable Halocarbons (624/8260)
Count (hemodialysis & all others) /2f\Volatile Halocarbons 2. Purgeabie Aromatics (624/8260)
2. Coliform P/A (public supplies) (.ZZVoiatiie Aromatics (524) I 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. Microexfractables (504) 5. Organochlorine Pesticides (608/8081)
^Microscopic ^6. Pesticides (507) 6. PCB’s (Arochlors) (608/8081)
Hwacroscopic .^t) Pesticides/PCB screen (508) 7. Methoprene (616)
a PCB as Decachiorobiphenyl (508A) 8, Herbicides (EPAI 978/8151)
ither: 9^ Herbicides (515) 9. Pesticides (SMI8/6630)
6^ Pesticides (525) ||l|sB;|||||l||ji|l| 10. Petroleum Hydrocarbon Scan (310-13)
Refrigerated? yes no
IT Carbamate Pesticides (531) 11. Glycols
Chlorinated:? i yes no 12. Glyphosate (547) 12. Acid Extractabies (625/8270)
13. Diquat (549) 13,^ Base Neutral Extractables (625/8270)
Free Chlorine Res;,
Total Chlorine Res:-
mg/L^
mg/L
14. Chlorination Disinfection Byproducts (551)
15. Haloacetic Acids (552)
(gjGC/MS Semivoiatiie Unknown Scan
15. Purgeabie Halocarbons (DEF)i
■B
16.' Pesticides (SM18/6630) 16. Purgeable Aromatics (DEF)
pH 17. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB's (DEF)
18. Other;„_ _____ _____ _ __ _______ 18. Other:. . .... ________
■
INORGANIC ANALYSIS REQUESTED - Lab#:
||||ji:|||g|ggg?g:?gggg|gggl
?|g®|8Hgf?gggggggSgllg^ 20. Acidity
g.
WFg... - 39. Aluminum
igyg-..g.-O
F,.g’ V
59'. Potassium
iSililOilJglliggliiligliig 21. Alkalinity, as CaCOa go? Antimony
22, Bromide ''41. Arsenic 61.. Silver
4. Conductivity 23, Bromate/Chlorate/Chlorite 42, Barium /eal Sodium
5. Corrosivity (temp:®C)- 24. Chloride f43. Beryllium (63. Thallium
6. BOD (5 day) 25. Cyanide ' 44. Boron 7645 Vanadium
7. Soluble BOD (5 day) 26. Fluoride 45. Cadmium '■'65. Zinc
8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOs 46. Calcium, as CaCOa
9, Chemical Oxygen Demand 28. Nitrogen, Ammonia as N {4.7. Calcium, Ca*^ 66?MetalFCN
10. Dissolved Oxygen 29. Nitrogen, Nitrate as N 48. Chromium, Total 67. Vol.hl-..
11. Total Organic Carbon 30. Nitrogen, Nitrite as N _4.9. Chromium, Hexavalent:
12. Total Organic Halides 31. Nitrogen, Total Kjeldahl as N f50.Cobalt 69. Pesticides/PCB's
gljT Solids, Percent (%) 32. Oil an Grease M-Copper 70. Disk Deliverables
IH^olids, Settleable
’^PBolids, Suspended TCLP
16. Solids, Total I Ci
I
17. Solids, Total Dissolved
18. Solids,'fbtal Volatile
18. Solids,-total
il9.:Other:
Volatile
_ _____
37. Surfactants
38. UV254
gG Mercmy
(S^Molybdenum
g,
, -
■
58. Nickel gg I
■MM ■MMI ■i
NYC-WTC_000072055
OCR can misread numbers and units. Confirm readings against the page image before using them.