NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
ster WESTCHESTER COUNTY LABORATORIES AND RESEARCH
vcom
2 Dana Road, Valhalla, New York 10595
(914) 593-5575
NYS-ELAP No. 10108
Time/Date Set: Form A-70 (rev.1/96)
ghpletype (circle one):
(Potable 3. Non Potable Treated Bottle #’s: X5068 94
aam
2. Non Potable •4. Other Chain of Custody? yes no
Time/Date Collected: 2/570/ /22% Comments:
Collected By: U4/AS Agency Code: PWS#:_______ Source ID: .Type Descriptor
Collected From: Bill to:
Location’s/Individual’s Name AA-5Fc
Street________________ ___________________________
Name/Company
Street________
City/St/Zip___________________ :_____________________ City/St/Zip
Identification of Source _ _____________________________ Phone#:_____ _ Fax#:.
Collection Point. SeS0s0 ______ CA,CH, Bl? Check#:
-AmoyS,omDMard
BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ANIC NONPOTABLE/SOLR ANALYSIS '
Lab#:____________________ Lab#:__________________
(circle tests) (circle tests) _
-S3 . Purgeable
• &*10"
1
1. Heterotrophic Plate Trihalomethanes (524) ( /22 3 4 Halocarbons (624/8260).
Count (hemodialysis & all others) Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260)
2. Coliform P/A (public supplies) Volatile Aromatics (524) 99 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. Pesticides (507) 6. PCB’s (Arochlors) (608/8081)
6. Macroscopic ( Pesticides/PCB screen (508) 7. Methoprene (616) "
7Pl 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151) i,
her:--------------- — 9. Herbicides (515) 9. Pesticides (SM18/6630) $3
d0) Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13)
Refrigerated? yes no 11. Carbamate Pesticides (531) 11. Glycols p
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 (5.Haloacetic Acids (552) 15. Purgeable Halocarbons (DEF) *:
16. Pesticides (SM18/6630) 16. Purgeable Aromatics (DEF) s,
pH 17. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB’s (DEF) 4
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 C -
5. Corrosivity (temp: °C)
24. Chloride
25. Cyanide
43. Beryllium
44. Boron
63. Thallium *<
64. Vanadium
P
6. BOD (5 day) r
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
49. Chromium, Hexavalent
67. Volatiles
11. Total Organic Carbon 30. Nitrogen, Nitrite as N 68.Serrii-vlolatiles
12. Total Organic Halides 31. Nitrogen, Total Kjeldahl as N SO.Cobalt 69. Pesticides/PCB’s
13. Solids, Percent (%) 32. 011 an Grease 51. Copper 70. Disk Deliverables
14. Solids, Settleable 33. Phenol 52. Iron
TCLP
GSolids, 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
18. Solids, Total Volatile 37. Surfactants 56. Mercury
38. UV254 57 Molybdenum 74. TCLP-Volatiles
• 19. Other________________ 75.TCLP-BNAs
58. Nickel
_===
NYC-WTC_000025889
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