NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
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ovcom WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
(914) 593-5575
NYS-ELAP No. 10108
Time/Date Set: Form A-70 (rev.1/96)
@npleType (circle one):
Cy Potable 3. Non Potable Treated Bottle #‘s: AFS50
2. Non Potable 4. Other _____________________ Chain of Custody? yes no
Time/Date Collected: £/46/ 0%0/ AS
Comments:
Collected By:AS Agency Code: PWS#:________ Source ID: .Type Descriptor:
Collected From: Bill to:
Location’s/Individual’s Name. 4/24 4/67/ so< Name/Company
Street Street_________
City/St/Zip_________ City/St/Zip
Identification of Source Phone#: _ Fax#:
Collection Point 3x S8 CA.CH. Bl? ' Check# Amount$
BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLEZ SOLID ANALYSIS
Lab#:________ ‘________
(circle tests)
Lab#: ----- 22240g
(circle tests) 9 " f •
---
1. Heterotrophic Plate 1. Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260)
Count (hemodialysis & all others) 2. Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260) 23
2. Coliform P/A (public supplies) 3. Volatile Aromatics (524) —
3. Acrolein & Acrylonitrile (624)
3. Coliform MPN (priv well, raw, stp) -.As
4. Total Trihalomethane Potential (510) 4. Phthalates (625/8270) , ‘J
4. Fecal Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8081)'
5. Microscopic 6. Pesticides (507) 6. PCB’s (Arochlors) (608/8081)
6. Macroscopic 7.Pesticides/PCB screen (508) 7. Methoprene (616)
7.API 8. PCB as Decachlorobiphenyl (508A)
Gher:__________ 8. Herbicides (EPA1978/8151) '0
9. Herbicides (515) 9. Pesticides (SM18/6630)
Refrigerated?yes no 10) Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13) ;
11. Carbamate Pesticides (531) 11. Glycols
Chlorinated:? yes no 12. Glyphosate (547) 12. Acid Extractables (625/8270)
13. Diquat (549) 13. Base Neutral Extractables (625/8270)
Free Chlorine Res: mg/L 14. Chlorination Disinfection Byproducts (551) 14. GC/MS Semivolatile Unknown Scan
Total Chlorine Res: mg/L 15. Haloacetic Acids (552) _ 15. Purgeable Halocarbons (DEF)
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#: 1 C3 —*
(circle tests) "S C
1. Color 20. Acidity 39. Aluminum 59. Potassium CT-
2. Turbidity 21. Alkalinity, as CaCOs 40. Antimony 60. Selenium,
3. pH 22. Bromide 41. Arsenic 61. Silver 4
4. Conductivity 23. Bromate/Chlorate/Chlorite 42. Barium 62. Sodium ;
5. Corrosivity (temp: 9C) 24. Chloride 43. Beryllium 63. Thallium
6. BOD (5 day) 25. Cyanide 44. Boron 64. 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 CaCOs CLP
9. Chemical Oxygen Demand 28. Nitrogen, Ammonia as N 47. Calcium, Ca+2 66. Metals/CN
10. Dissolved Oxygen 29. Nitrogen, Nitrate as N 48. Chromium, Total 67. Volatiles
11. Total Organic Carbon 30. Nitrogen, Nitrite as N 49. Chromium, Hexavalent 68. Semi-violatiles
12. Total Organic Halides 31. Nitrogen, Total Kjeldahl as N 50. Cobalt 69. Pesticides/PCB’s
13. Solids, Percent (%) 32. Oil an Grease 51. Copper 70. Disk Deliverables
14. Solids, Settleable 33. Phenol 52. Iron
34. Phosphorus Total as P 53.Lead TCLP
IK1 iolids, Suspended
iolids, Total 35. Phosphorus, Ortho as P 54 Magnesium
71 TCLP-Metals
72.TCLP-Pesticldes
17. Solids, Total Dissolved 36. Sulfates 55 Manganese
73. TCLP-Herbicldes
18. Solids, Total Volatile 37. Surfactants 56. Mercury
19. Other____________ 38. UV254 57 Molybdenum 74. TCLP-Volatiles
75.TCLP-BNA's
58. Nickel
- - sama -= ,,K al i . - sih
NYC-WTC_000025710
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