NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
ester
rov.com
Time/Date Set:
WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
(914) 593-5575
(9
NYS-ELAP No. 10108
Form A-70 (rev. 1/96)
CpleType (circle one):
1.Potable 3. Non Potable Treated Bottle #s: 7658
2. Non Potable 4. Other___________ Chain of Custody? yes no
Time/Date Collected: _{(es Vece tr5 Comments:
Collected By: W I MT Agency Code: _ Source ID: .Type Descriptor:
Collected From: Bill to:
Location's/Individual's Name Asautew) ASUR Name/Company
Street________________ Street________
City/St/Zip________ _ City/St/Zip_____
Identification of Source Phone#: _ _____ Fax
Collection Point “ =DwSp *
CA,CH, Bl? Check#: Amount$
*t 48 ': ■
BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS
Lab#:_________ _
(circle tests) 2-743-
1. Heterotrophic Plate 1. Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260)
Count (hemodialysis & all others) 2. Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260) f
2. Coliform P/A (public supplies) 3. Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624)
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. PCB’s (Arochlors) (608/8081) —
6. Macroscopic $ Pesticides (507) 7. Methoprene (616)
Pesticides/PCB screen (508)
7_API 8.PCB
1 as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151)
_ 9. Herbicides (515) 9. Pesticides (SM18/6630)
Refrigerated?yes no ‘10 Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13)
-I. 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#: CO
(circle tests) -C
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
g Solids, Suspended 71 .TCLP-Metals
W Solids, Total 35. Phosphorus, Ortho as P 54 Magnesium
72.TCLP-Pestlcides
17. Solids, Total Dissolved 36. Sulfates 55 Manganese
56. Mercury 73. TCLP-Herbicides
18. Solids, Total Volatile 37. Surfactants
57 Molybdenum 74. TCLP-Volatiles
19. Other:________________ 38. UV254 75.TCLP-BNA’s
58. Nickel
istinis
NYC-WTC_000025704
OCR can misread numbers and units. Confirm readings against the page image before using them.