NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
tester WESTCHESTER COUNTY LABORATORIES AND RESEARCH
nov.com
2 Dana Road, Valhalla, New York 10595
(914) 593-5575
NYS-ELAP No. 10108
Time/Date Set: Form A-70 (rev. 1/96)
GipleType (circle one):
(1. Potable 3. Non Potable Treated Bottle #s: 27655
2. Non Potable 4. Other_______________________ Chain of Custody? vest no
Time/Date Collected: 3© Comments:
Collected By:Agency Code: PWS#:_______ Source ID: .Type Descriptor
Collected From: , Bill to:
Location's/Individual’s Name A1e,es RSVP- Name/Company _
Street________________________________________ Street________
City/St/Zip___________________ :_________ :______ _ City/St/Zip
Identification of Source . _______________________ Phone#: _ Fax#:
Collection Point 590*,;
CA,CH, Bl?_ Check#: Amounts.
- . 1*— : t . -
BACTERIOLOGICAL ANALYSIS
Lab#:____________________
(circle tests)
&MANLCZRTZOY_
(circle tests) ‘Y"
ORGANIC NONPOTABLE/SOLID ANALYSIS
1. Heterotrophic Plate 1. Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260)
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) 2
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)
6. Macroscopic (Pesticides/PCB screen (508) 7. Methoprene (616)
7.API 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151)
_ 9. Herbicides (515) 9. Pesticides (SM18/6630)
U
Refrigerated? yes no 10. Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13)'.
IT. Carbamate Pesticides (531) 11. Glycols n
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#:
(circle tests)
1. Color 20. Acidity 39. Aluminum 59. Potassium
2. Turbidity 21. Alkalinity, as CaCOs 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 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
at Solids, Suspended 71 .TCLP-Metals
SSolids, Total 35. Phosphorus, Ortho as P 54 Magnesium
72.TCLP-Pesticides
17. Solids, Total Dissolved 36. Sulfates 55 Manganese
73. TCLP-Herbicides
18. Solids, Total Volatile 37. Surfactants 56. Mercury
57 Molybdenum 74. TCLP-Volatiles
19. Other:________________ 38. UV254
75. TCLP-BNA's
58. Nickel
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NYC-WTC_000025701
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