NYC 9/11 Public Portal Document
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ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
Westchester county laboratories and research
2 Dana Road, Valhalla, New York 10595
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(914) 231-1620 Fax (914) 231-1772
NYS-ELAP No 10108
Time/Date Set: FonnA-70(r8v.10/01)
Sample Type (circle one);
f ^p»otable 3. Non Potable Trsated Bottle #’s: .<3. rwz--i
ZNonPoteWe 4. Other_____________ . Chain of Custody? - Vias _ No
' Time/Date Collected: ■ Comments:
I
Collected By: T- Agency Code: ___ PWS#: Source ID:1 .Type Descriptor.
Collected From: 42^ BUI to:
Location’s/lndlvidual’s Name _________ Name/Company_
•i'Str^________________________ _ _____ Street.;______ _
City/St/Zip_______^_______________________ _ Clty/St/Zip,
Identificatlonof'Source _____ Phone#-. —;P^. '-j
CollectlonPolnt _ I CA,CH, BI? ZZ
BACTERIOLOGICAL ANALYSIS Lab#:
> 7 ■. - <
ORGANIC POTABLE ANALYSIS
(hemodialysis & ail others) _TrihaIomethane8 (524) __ Pu^8abl8 Heiocarb6ns (624/8260) - |
ii^CcHlforrn P/A (Public sidles) _ Volatile Halocarbons (524) Puigeable Aromatics (624/8260) S
_ Volatile Aromatics (524) A^irt i
,-_i' Cpjtfe<tn,M^ (priv wen. raw, stp)
Coliform (all samples) _ Total Trihalomethane Potential (510) _Organochtorfoe>^tlcidee (608/8081), -'
_3 Microstroplc _ Microextractables (504)
__ Maraoscopic _Pesticldesri’CBscreen (508)
__ PCB as Decachlorobiphenyl (508A)
_Herbicldes(515) _ Petroleum Hydrorarbon Scan (310-13) jm .
--------------
__ Pesticides (526)
^f^ft^fiSetsd?^..___yes__no _CarbamatB Pestlcides (531)
(^nated:? yes ^no _ Glyphosate (547)
_Diquat(549)
mg/L _ Chlorination Disinfection Byproducts (651)
TBiChlorineRes: ______ mg/L < _jHaloa<»acAcide:(552) ?■ __ Other ‘. , ' , ' . _ V;
I ANALYSIS
__ Other Pesticides (SM18/6830)
__UCMRU8t1
_MtBE Only (524)
\
.. -... /..... ..
mother '< .>
I INORGANIC ANALYSIS REQUESTED -
'' ' K.'‘ • .3 i'
I __ Color
gftjrbjdlty
__ Acidity
Alkalinity '
_ Bromide
B^uminum
.^^Antirndny
>
J '__ Potassium
j*-'
mo
jU_Conductivity
_ Corrc»lvity (temp:..x_’C)
__Bromate/Chlorate/Chlorite
_Chlorlde .^fBeryllium
Sodium
i'-- •'
yiBODl(5day)
Carbonaceous BOD (5 day)
Soluble BOD (5 day)
IK B, Chemlcal Oxygen Demand
_Cyahlde
_ Fluoride
_ Hardness. Total as CaCOa
__ Nitrogen, Ammonia as N
„Cadmlum
__ Calcium, las CaCOa j
_Calcium,Ca*2
' i __Vanad
\^"2inc :
CLP
tftli
__D}8solved Oj^gen _ Nitrogen, Nitrate as N ±*Chiotnlum,T(^f ■Jll I
r- Total Organic Carbon
__. Total Organic Halides
_ Nitrogen, Nitrite as N __ Chromium, Hexavalent
_ Nitrogen, Total l^eldahl as N j^Cobalt B
B7 SoHd8, Percehl (%) Oil and Grease ±:^>oppiw
R' _'Soiids,Settieable __ ..Ptierfol' Jilron'
K'' __ Solids, Suspended __ Phosphorus Total as P ^i Lead ,
Solids, Total __ Phosphorus, Ortho as P _ Magnesium
Solids, Total Dissolved ■..-TCLR’^WcidiB®-
__ Sulfetes _:i Manganese
__ Surfactants .B^Mercury __TCLP-Herbicfdes
_ Solids, Total Vdaflle ,
_TCLP-Voiatiies
_ UV254 r:; Molybdenum
_TCLP-8N«b
iXNIctel
NYC-WTC_000074904
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