NYC 9/11 Public Portal Document
8'7'
35;?B5Ti
ENVIRONMENTAL
SlujSk. SERVICES SAMPLE SUBMISSION FOllM
3: ■-^■-,'=2 Dans, VdfhSiJd* NiSW YC^C: jOoSSi,.
Y (914)231-I8ib Pax{914)^3lJl772';
11
I ■'> • 7l7NYBMA{»T^k^
7:77Fotfa Ar^ (re^C^j. 7
'''X ‘ ' "" '•..•’s’
> -'ll"-'""'
V Potable 3. Non Potable Traafed
1-7 _ Chain of Custody? X-Yes-__ No '
fe
Bp . PWS #;Source ID: UXu-iype Descriptor Jx.
t ^'-,f^me^D<^pany.X±X«JLX7X£Xyi^
———-x_
I -idSiwep______ —,_____ L_________ x ,, .7 7 .dty/SVZip .iLxXX-jOMOS--^^r-^0^^
.;lderw«i-ofsource_£ --------------
B 1‘CollectionPoint_________________ ■ ' '
■ --------------i. _ ' ‘"f^one^XxX-XxXSIXXF^d!^ Ji.
»?5 j_rXX2x_____________ ' '77 •'
” I CA,CH, BI? .Ch^ XxiX- /^ntSUxSx;
bXctef66l6gic/u. analysis t
i
it
ORGANIC POTABLE ANALYSIS
__Trihalomethanes (524);
'iifVofaHie Halocarbons (524)
II
iLi VPiatlle Aromafics (524} ; ;
i :Xf^^^oOWT^W^sainpied) X'l iiifcfel Trihalomethane pots^sU (SiO)
__Microextractabl88 (504) 7
„ Pesticides/PCB screen (508) * Heiblddes (SM18/6630 8151) I
API - X PCS as Decachiorobiphenyl (508A)
X Other 'J___ XHerbIcldes (515)
__ Pesticides (525)
yj. Refrigerated?___ yes___ no __ Carbamate Pesticides (531)
Chlorin^:?___ yes___ no _Glyphosate(547)
XtMquiat (549) XGC/MS Unknown Scan > V
’ Free Chlorine Res:_______ mg/L
X. Chlorination Disinfection Byproducts (651) X Pb1Mla^ (®06MS)
Total Chlorine Res:mg/L X HafeacetIc Adds (652) X,.6ttfetf2XxXXil^2SXiX^S
X PH.; ■ XC«h^ Peteles (SM18«630) ‘ __________ 3^^XX_Xx .
••5
XUCMRListT " ' ' '.. ' " X . ''nW‘
;■ ^R^^HE«KAL ANALYSIS ^MtBE Only (524)
I i52x23wEiS^BS
ft 3?B?W=55=5==a^—------------------------------------ 1
-fe' INORGANIC ANALYSIS REQUESTED - tab#: X'33
I _. Coior __ Acidity
"yX ^l7/--i 7:;XAlkalinity- ,
_ Aluminum
__ Antimony . - __Wdniufa-'7
Xi irf4YY7''7 ''7\-;__Bromidei .:_jfesenlc ■<.stiver
, — Bromate/Chlorate/Chlorlte _ Barium,
7 X-Corros|vity (temp:____‘’C)'
F *X'’eop(«W)7.?:;'X
X Carbonaceous BOD (5 day)
X- Soluble BOD (5 day):
X ChemIcd Oxygen Demand
;
__ Chlorid8
";_,Ru««1tlev;
Hardness, Total as CaCOs
_ _Nitrogen, Ammonla as N
_i.Bet^llum
__ Boron'
___Cadmlum i;
7
_ Calcium, as CaCOs
__ Calcium, Ca«:,
„Vanadiam
•^Metals^JN
X
_Disso1v8d Oxygen __ Nltrogen, Nitrate as N _Chromium.Totar.
Total Organic Carbon „ Volatiles ;
_ Nfax^en, Nitrite as N __ Chromium, Hexavalent __ Seml-violatiles 1
X:/WOroanicH^^ __ Nitrogen^ Total Kjeldahl as N .XCobalt.-..
__ Sollds, Perc8nt {%) ' ? „Pesticid8s/PGB’s
OU and Grease ^Copper :
7X7M<l8/Sottleable ■ ■ _ Phenol' ;_ Iron'..
7 X Solids, Suspended __ Phosphorus Total as P. _Lead
’ _ So!lds, Total „TCLP-Metals
__ Phosphorus, Orthoas P __ Magnesium _TCLP-Pesticides
: X Solids. Total Dissolved __ Sulfates . __ Manganese .•
; X. Solids* Tbtei Volatile __TCLP-Herbicides
_ Surfactants __ Mercury X-jnOLP^felatiles?
•‘ Other: _________ _ UV254 „ Molypdenum i <;■ ■■■,i-
Nickel
; ,XLi_';LL-.r.Aife
NYC-\/VTC_000075126
OCR can misread numbers and units. Confirm readings against the page image before using them.