NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
ster WESTCHESTER COUNTY LABORATORIES AND RESEARCH
i com 2 Dana Road, Valhalla, New York 10595
(914) 593-5575
NYS-ELAP No. 10108
Time/Date Set: Form A-70 (rev.1/96)
SpleType (circle one):
(1 Potable 3. Non Potable Treated Bottle #‘s: -8002
2. Non Potable 4. Other __________________ Chain of Custody? yes no
Time/Date Collected: 070/ /53 Comments:
Collected By:. V/S _ Agency Code: PWS# Source ID: .Type Descriptor
Collected From: Bill to:
Location’s/Individual’s Name — -5/FcAf6 SAA lame/Comdanv
Street________________ ___________________________ Street_____ _
City/St/Zip_________ ___ • . City/St/Zip _
Identification of Source _ .. . . • ... . Phone# _____—Fax—_______ ___
Collection Point .-/EScsC : — a : ——----- --------------------------- ------
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Check#: Amounts
BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS t ORGANIC NONPOTABLE/SOLID ANALYSIS
Lab#:________ :______ Lab#:
(circle tests)
1. Heterotrophic Plate
Count (hemodialysis & all others)
(circle tests)
1. Trihalomethanes (524) / _
8 X
(2. Volatile Halocarbons (524) *
s19
A. 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 (priv wen, 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 Pesticides (507) 6. PCB’s (Arochlors) (608/8081) ..
6. Macroscopic Pesticides/PCB screen (508) 7. Methoprene (616) 90
8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151) 2
en Herbicides (515) 9. Pesticides (SM18/6630)
Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13) _
Refrigerated? yes no
11. Carbamate Pesticides (531) 11. Glycols 0
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
(15. Haloacetic Acids (552) 15. Purgeable Halocarbons (DEF)
Total Chlorine Res: mg/L %*
16. Pesticides (SM18/6630) 16. Purgeable Aromatics (DEF)
pH 17. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB’s (DEF)
18. _ ______________ ;___________ 18. Other__________________
INORGANIC ANALYSIS REQUESTED - Lab#:
(circle tests)
1. Color 20. Acidity 39. Aluminum 59. Potassium
2. Turbidity 21. Alkalinity, as CaCO3 40. Antimony 60. Selenium
3. pH 22. Bromide 41. Arsenic 61. Silver S
4. Conductivity 23. Bromate/Chlorate/Chlorite 42. Barium 62. Sodium ■ 5 =*
5. Corrosivity (temp: °C) 24. Chloride 43. Beryllium 63. Thallium =d -
6. BOD (5 day) 25. Cyanide 44. Boron 64. Vanadium a
7. Soluble BOD (5 day) 26. Fluoride 45. Cadmium 65. Zinc I
8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCO3 46. Calcium, as CaCOs CLP i
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
53.Lead TCLP
(Solids, Suspended 34. Phosphorus Total as P 71 .TCLP-Metals
> “Solids, Total 35. Phosphorus, Ortho as P 54 Magnesium
72.TCLP-Pesticides
17. Solids, Total Dissolved 36. Sulfates 55 Manganese
73. TCLP-Herbicides
18. Solids, Total Volatile 37. Surfactants 56. Mercury
74. TCLP-Volatiles
. 19. Other:________________ 38. UV254 57 Molyodenum 75.TCLP-BNA’S
58. Nickel
NYC-WTC_000025881
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