NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
ster
1 iv.com WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
15
(914) 593-5575
NYS-ELAP No. 10108
Time/Date Set: Form A-70 (rev.1/96)
sMRpietype (circle one):
(1 Potable 3. Non Potable Treated Bottle *s: 2067 /3/ 3 So
2. Non Potable 4. Other__________________ Chain of Custody? yes no
Time/Date Collected: 2-/s- 0f 9855
Comments:
Collected By: VA/AS Agency Code: PWS#:_______ Source ID: .Type Descriptor:
Collected From: Bill to:
Location’s/Individual’s Name A-S/6E/L Name/Company _
Street________________
7AES Street
City/St/Zip ________ ___________ :________ ____ _____________
Identification of Source___ . 3 _ t/ Phone#: _ Faxif:
Collection Point
BACTERIOLOGICAL ANALYSIS
$773 —/p9
—Scacnihe
ORGANIC POTABLE ANAGYSS T
Check# Amounts ”
.p-==-=================y========p=van9=9==.=y==59
IC NONPOTABJ.E/SOLJD ANALYSIS
Lab#:____________________ Lab#:_______ 4L C X ■■ w:
(circle tests) (circle tests) i _
1. Heterotrophic Plate
Count (hemodialysis & all others)
1. Trihalomethanes (524)
2) Volatile Halocarbons (524)
I ? 1. Purgeable Halocarbons (624/8260)
2. Purgeable Aromatics (624/8260)
2. Coliform P/A (public supplies) 3. Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624)
3. Coliform MPN (privwell, 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) 57
r—
Refrigerated? yes no 6
8. PCB as Decachlorobiphenyl (508A)
Herbicides (515)
Pesticides (525)
8. Herbicides (EPA1978/8151)
9. Pesticides (SM18/6630) to
10. Petroleum Hydrocarbon Scan (310-13) ''
11. Carbamate Pesticides (531) 11. Glycols 6
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) L
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 e
4. Conductivity 23. Bromate/Chlorate/Chlorite 42. Barium 62. Sodium Q 9J
5. Corrosivity (temp: °C) 24. Chloride 43. Beryllium 63. Thailium ** **
6. BOD (5 day) 25. Cyanide 44. Boron 64. Vanadium ...
7. Soluble BOD (5 day) 26. Fluoride 45. Cadmium 65. Zinc 1
8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOs 46. Calcium, as CaCOs CLP i
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
(Folids, Suspended 34. Phosphorus Total as P 53.Lead 71 .TCLP-Metals
’ 1. Solids, Total 35. Phosphorus, Ortho as P 54 Magnesium
55 Manganese
72. TCLP-Pesticides
17. Solids, Total Dissolved 36. Sulfates
56. Mercury
73. TCLP-Herbicides
18. Solids, Total Volatile 37. Surfactants 74. TCLP-Volatiles
• 19. Other________________ 38. UV254 57 Molybdenum 75.TCLP-BNA’S
58. Nickel
NYC-WTC_000025884
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