NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
h 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)
pie Type (circle one):
(1)Potable 3. Non Potable Treated Bottle _ _______ 28969 32352
2. Non Potable 4. Other Chain of Custody? yes no
Time/Date Collected:
Collected By: VA/AF
_ 7-/4-0/ /£25 Comments:
Agency Code: _ Source ID: .Type Descriptor:
Collected From: Bill to:
Location’s/Individual’s Name AX /AEAL SHAEName/Company
Street________________ _____________ ;_____________ Street
___________________ _
Identification of Source 1 :_____________ __ Phone#: -Faxif:
Collection Point < t5785i32350 ' CA,CH,BI? Check#: Amounts.
bacteriologicalAnalysis ORGANIC POTABLE ANALYSIS _ NIC NONPOTABLE/SOLID ANALYSIS
Lab#: . 5.
Lab#:---- -------- 2
(circle tests) (circle tests) /51 -
1. Heterotrophic Plate 1. Trihalomethanes (524) ( • • 1. Purgeable Halocarbons (624/8260)
Count (hemodialysis & an others) 2. Volatile Halocarbons ___________ — 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 Potential (510) 4. Phthalates (625/8270)
4. Fecal Coliform (an samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8081) '
5. Microscopic 6. Pesticides (507) 6. PCB’s (Arochlors) (608/8081)
6. Macroscopic C Pesticides/PCB screen (508) 7. Methoprene (616)
Gr—
Refrigerated? yes no
8. PCB as Decachlorobiphenyl (508A)
9. Herbicides (515)
do. Pesticides (525)
8. Herbicides (EPA1978/8151)
9. Pesticides (SM18/6630)
10. Petroleum Hydrocarbon Scan (310-13)
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. Potassium
e , *,
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+Z 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
Solids, Total 35. Phosphorus, Ortho as P 54 Magnesium
72.TCLP-Pesticldes
17. Solids, Total Dissolved 36. Sulfates 55 Manganese
73.TCLP-Herbicides
18. Solids, Total Volatile 37. Surfactants "56. Mercury
38. UV254 57 Molybdenum 74. TCLP-Volatiles
. 19. Other________________ 75.TCLP-BNA‘s
58. Nickel
NYC-WTC_000025878
OCR can misread numbers and units. Confirm readings against the page image before using them.