NYC 9/11 Public Portal Document
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ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
ster WESTCHESTER COUNTY LABORATORIES AND RESEARCH
iv.com
2 Dana Road, Valhalla, New York 10595
(914) 593-5575
NYS-ELAP No. 10108
Time/Date Set: Form A-70 (rev.1/96)
SpleType (circle one):
TPotable 3. Non Potable Treated Bottle #s: 7512 G (od
2. Non Potable 4. Other Chain of Custody? _____no
Time/Date Collected: SIot 76 S tvS Comments:
Collected By:____________ Agency Code: _ Source ID: .Type Descriptor
Collected From: Bill to:
Location’s/Individual’s Name Ktew) GSVe Name/Company _
Street__________________ Street_________
City/St/Zip. City/St/Zip
Identification of Source _ Phone#: _ ______ Fax#:
Collection Point . ; -Ox3 CA,CH, Bl? Check#: Amounts.
• F
wl. n
BACTERIOLOGICAL ANALYSIS ORGANIC 0A57385 ORGANIC NONPOTABLE/SOLID ANALYSIS
Lab#:_________ _____________ M
(circle tests) (circle tests)
1. Heterotrophic Plate 1. Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260) E
Count (hemodialysis & all others) 2. Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260)
2. Coliform P/A (public supplies) 3. Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624)
0
3. Coliform MPN (priv well, raw, stp) 4. Total Trihalomethane Potential (510) 4. Phthalates (625/8270)
4. Fecal Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8081) .
5. Microscopic 6. Pesticides (507) 6. PCB’s (Arochlors) (608/8081) C
6. Macroscopic C Pesticides/PCB screen (508) 7. Methoprene (616)
7.API 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151)
Gher 9. Herbicides (515) 9. Pesticides (SM18/6630)
( Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13)
Refrigerated? yes no
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) & c
16. Pesticides (SM18/6630) 16. Purgeable Aromatics (DEF);
pH 17. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB’s (DEF) asa
18. Other__________________________ 18. Other__________ C
T
INORGANIC ANALYSIS REQUESTED - Lab#:
(circle tests)
1. Color 20. Acidity 39. Aluminum 59. Potassium r
2. Turbidity 21. Alkalinity, as CaCO3 40. Antimony 60. Selenium
3. pH 22. Bromide 41. Arsenic 61. Silver
4. Conductivity 23. Bromate/Chlorate/Chlorite 42. Barium 62. Sodium
5. Corrosivity (temp:. °C)
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 CaCOa 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
TCLP
g Solids, Suspended 34. Phosphorus Total as P 53.Lead
71 .TCLP-Metals
NSolids, Total 35. Phosphorus, Ortho as P 54 Magnesium
72.TCLP-Pesticldes
17. Solids, Total Dissolved 36. Sulfates 55 Manganese
73. TCLP-Herbicides
18. Solids, Total Volatile 37. Surfactants 56. Mercury
74. TCLP-Volatiles
19. Other:_________________ 38. UV254 57 Molybdenum
75.TCLP-BNAs
58. Nickel
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NYC-WTC_000025699
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