NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM . i* ACco
&
WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
(914)231-1620 Fax (914) 231-1772
NYS-ELAP No. 10108
Time/Date Set: /Form A-70 (rev.10/01) -
Sample Type (circle one): C P P/ G sr
1. Potable 3. Non Potable Treated Bottle #s: 020227,268,773435 /36%
2. Non Potable 4. Other______________________ Chain of Custody? Yes No
Time/Date Collected: 9,5522 5//5/02
Comments:
Collected By: J. 6e,7sE. Agency Code: PWS #:_______ Source ID: .Type Descriptor:
Collected From: Bill to:
Location’s/Individual’s Name /506/ Name/Company
Street________________ Street________
City/St/Zip_ ___________ City/St/Zip
Identification of Source Phone#:______ Fax#:
Collection Point 79550
CA.CH, Bl? Check#: Amounts.
BACTERIOLOGICAL ANALYSIS Lab#:
Lab#:____________ ________
ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS
Heterotrophic Plate Count __ Trihalomethanes (524)
(hemodialysis & all others) Purgeable Halocarbons (624/8260)
__ Coliform P/A (Public supplies) Volatile Halocarbons (524) Purgeable Aromatics (624/8260)
__ Coliform MPN (priv well, raw, stp) __ Volatile Aromatics (524) __ Acrolein & Acrylonitrile (8260)
Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) ___ Pesticides (608/8081)
Microscopic ___ (504) _ PCB’s (Arochlors) (608/8081)
Macroscopic ___ screen (508) Herbicides (SM18/6630,8151)
_ API __ PCB as Decachlorobiphenyl (508A) Other Pesticides (SM18/6630)
Other:__________________ _ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13)
Pesticides (525) __ Glycols in Water
Refrigerated?yes no .Carbamate Pesticides (531) _ Acid Extractables (625/8270)
Chlorinated:?yes no __ Glyphosate (547) __ Base Neutral Extractables (625/8270)
. Diquat (549) GC/MS Unknown Scan
Free Chlorine Res: .mg/L __ Chlorination Disinfection Byproducts (551) _ Phthalates (606MS)
Total Chlorine Res: .mg/L _ Acids (552) __ Other:_________________________
pH __________ _ Other Pesticides (SM18/6630)
_UCMRList1
RADIOCHEMICAL ANALYSIS MtBE Only (524)
.Radon
Other__________________
INORGANIC ANALYSIS REQUESTED - Lab#:
Color
__ Turbidity
Acidity
113 •Aluminum — Potassium
Alkalinity ^Antimony • Selenium
_ pH Bromide • Arsenic L Silver
Conductivity _ _ • Barium __ Sodium
__ Corrosivity (temp: .°C) Chloride L Beryllium • Thallium
_ BOD (5 day) Cyanide __ Boron __ Vanadium
Carbonaceous BOD (5 day) Fluoride __ Cadmium LZinc
Soluble BOD (5 day) Hardness, Total as CaCOs __ Calcium, as CaCOs
Chemical Oxygen Demand Nitrogen, Ammonia as N CLP
__ Calcium, Ca*2
Dissolved Oxygen Nitrogen, Nitrate as N Chromium. Total _Metals/CN
Total Organic Carbon __ Nitrogen, Nitrite as N __ Volatiles
Chromium, Hexavalent __ Semi-violatiles
Total Organic Halides __ Nitrogen, Total Kjeldahl as N • Cobalt
__ Solids, Percent (%) Oil and Grease Pesticides/PCB’s
L Copper
__ Solids, Settleable Phenol LTron
Solids, Suspended __ Phosphorus Total as P TCLP
•Lead _TCLP-Metals
Solids, Total Phosphorus, Ortho as P __ Magnesium
__ Solids, Total Dissolved __ Sulfates • Manganese
_ _
_ Solids, Total Volatile __ Surfactants (✓Mercury _TCLP-Herbicides
• Other: 077_______ UV254 I Molybdenum _ _
_ TCLP-BNA’s
l Nickel
NYC-WTC_000013694
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