NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
seer WESTCHESTER COUNTY LABORATORIES AND RESEARCH
com
2 Dana Road, Valhalla, New York 10595
(914) 593-5575
NYS-ELAP No. 10108
Time/Date Set: Form A-70 (rev.1/96)
SumpleType (circle one): 9006
1. Potable 3. Non Potable Treated Bottle #‘s: 3050
2. Non Potable 4. Other Chain of Custody? yes no
Time/Date Collected: 7-/s
/F/s Comments:
Collected By: Agency Code: _ Source ID: .Type Descriptor
Collected From: Bill to:
Location’s/ndividual’s Name 4A-5/GCAL MAAES Name/Company
Street________________________________________________ Street______ _
City/St/Zip__________________ ___ ________________________ _
Identification of Source ________________________________ Phone#: Fax#f
Collection Point _____ She 3/0s0 ______ CA.CH.BI? Checki: / Amounts $7
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BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLDANALYsiS
—-----
Lab#:_______________________ Lab#:___________________
(circle tests) (circle tests)
1. Heterotrophic Plate 1. Trihalomethanes (524) A 1. Purgeable Halocarbons (624/8260)
Count (hemodialysis & all others) 2. Volatile Halocarbons 0^4) 2. Purgeable Aromatics (624/8260)
2. Coliform P/A (public supplies) 3. Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624) •
3. Coliform MPN (priv well, raw, stp) 4. Total Trihalomethane Poten [510) 4. Phthalates (625/8270)
4. Fecal Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8081)
5. Microscopic Pesticides (507) 6. PCB’s (Arochlors) (608/8081) 50
6. Macroscopic Pesticides/PCB screen (508) 7. Methoprene (616) 3
Gr— 8. PCB as Decachlorobiphenyl (508A)
6 Herbicides (515)
Pesticides (525)
8. Herbicides (EPA1978/8151)
9. Pesticides (SM18/6630)
a-
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)
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. Potassigm t mutet
2. Turbidity 21. Alkalinity, as CaCO3 40. Antimony 60. Seleni um P
3. pH 22. Bromide 41. Arsenic 61. Silver co
4. Conductivity 23. Bromate/Chlorate/Chlorite 42. Barium 62. Sodiui h
5. Corrosivity (temp: °C) 24. Chloride 43. Beryllium 63. Thallit m
6. BOD (5 day) 25. Cyanide 44. Boron 64. Vanac ium
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 TCLP
(Solids, Suspended 34. Phosphorus Total as P 53.Lead
71 .TCLP-Metals
* “Solids, Total 35. Phosphorus, Ortho as P 54 Magnesium
36. Sulfates 55 Manganese
72. TCLP-Pesticides
17. Solids, Total Dissolved 73. TCLP-Herbicides
37. Surfactants 56. Mercury
18. Solids, Total Volatile
. 19. Other__________________ 38. UV254 57 Molyodenum 74. TCLP-Volatiles
75.TCLP-BNAS
58. Nickel
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NYC-WTC_000025887
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