NYC 9/11 Public Portal Document
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ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM i ’ 2
WESTCHESTER COUNTY LABORATORIES AND RESEARCHIlg.
2 Dana Road, Valhalla, New York 10595 AM 8/1
(914)231-1620 Fax (914) 231-1772 • *— bl
NYS-ELAP No. 10108
Time/Date Set: Form A-70 (rev. 10/01)
Sample Type (circle one):
1. Potable 3. Non Potable Treated Bottle #’s: 0 3413 -7/L
2. Non Potable 4. Other Chain of Custody? Yes' No
Time/Date Collected: L| 870— , Comments:
Collected By: L5 Agency Code: he PWS #:________ Source ID: Type Descriptor:
Collected From: Bill to:
Location's/Individual's Name fO Name/Company
Street_________________ Street_________
City/St/Zip______________ City/St/Zip
Identification of Source Phone#:_______ Fax#:
Collection Point FRO CA,CH, Bl? Check#: Amounts.
BACTERIOLOGICAL ANALYSIS
Lab#:_______________________
ORGANIC
Lab#:
/C2CS
ORGANIC NONPOTABLE/ SOLID ANALYSIS
__ Heterotrophic Plate Count __ Trihalomethanes (524) __ Purgeable Halocarbons (624/8260)
(hemodialysis & all others)
__ 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) _ Organochlorine Pesticides (608/8081)
__ Microscopic __ Microextractables (504) _ PCB’s (Arochlors) (608/8081)
__ Macroscopic __ Pesticides/PCB 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) X GC/MS Unknown Scan
Free Chlorine Res: . mg/L __ Chlorination Disinfection Byproducts (551) _ Phthalates (606MS)
Total Chlorine Res: .mg/L __ Haloacetic Acids (552) _ Other:____________________________
__ Other Pesticides (SM18/6630)
pH ___________
_UCMR List 1
RADIOCHEMICAL ANALYSIS _MtBE Only (524)
Radon
__ Other____________________
INORGANIC ANALYSIS REQUESTED - Lab#:
Color __ Acidity __ Aluminum __ Potassium
Turbidity __ Alkalinity _ Antimony __ Selenium
_ PH __ Bromide __ Arsenic __ Silver
__ Conductivity __ Bromate/Chlorate/Chlorite Barium __ Sodium
__ Corrosivity (temp : °C) __ Chloride __ Beryllium __ Thallium
_ BOD (5 day) __ Cyanide __ Boron __ Vanadium
__ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Zinc
__ Soluble BOD (5 day) __ Hardness, Total as CaC03 __ Calcium, as CaCOs
Chemical Oxygen Demand CLP
__ Nitrogen, Ammonia as N __ Calcium, Ca*2
__ Dissolved Oxygen _ Metals/CN
__ Nitrogen, Nitrate as N __ Chromium, Total
__ Total Organic Carbon __ Volatiles
__ Nitrogen, Nitrite as N __ Chromium, Hexavalent
__ Semi-violatiles
__ Total Organic Halides __ Nitrogen, Total Kjeldahl as N __ Cobalt < .
__ Pesticides/PCB’s
Solids, Percent (%) __ Oil and Grease _ Copper s
__ Solids, Settleable __ Phenol __ Iron . TCLP
__ Solids, Suspended __ Phosphorus Total as P __ Lead
_TCLP-Metais
__ Solids, Total '__ Phosphorus, Ortho as P __ Magnesium
__ TCLP-Pesticides
__ Solids, Total Dissolved __ Sulfates __ Manganese
Solids, Total Volatile _TCLP-Herbicides
__ Surfactants __ Mercury
TCLP-Volatiles
__ Other:_________________ _ UV254 __ Molybdenum
_ TCLP-BNA’s
_ Nickel
NYC-WTC_000024332
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