NYC 9/11 Public Portal Document
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ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
ster WESTCHESTER COUNTY LABORATORIES AND RESEARCH
iv.com 15
2 Dana Road, Valhalla, New York 10595 9
(914) 593-5575
NYS-ELAP No. 10108
Time/Date Set: Form A-70 (rev.1/96)
pleType (circle one):
CPotable 3. Non Potable Treated Bottle #‘s: -500/ 30,262
2. Non Potable 4. Other___________ Chain of Custody? les no
Time/Date Collected: 7- /sa/ /24% Comments:
Collected By: _ Agency Code: PWS# Source ID: .Type Descriptor:
Collected From: • Bill to:
Location's/Individual’s Name. AA-S/EC/L _ 1 Name/Company_
Street TS/MPS Street
City/St/Zip___________________ :_ City/St/ZIp
Identification of Source __ ________________ __________ Phone#: ■ - Fax#
Collection Point $ie 30252
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Check#: Amounts
BACTERIOLOGICAL ANALYSIS
Lab#:_____________________
ORGANIC POTABLE
Lab#:
ANALYSIS 0
■ eryi
RGANIC NONPOTABLE/SOLID ANALYSIS
(circle teste) (circle tests) :
1. Heterotrophic Plate 1. Trihalomethanes (524). 1.Purgeable Halocarbons (624/8260)
Count (hemodialysis & aD others) 2. Volatile Halocarbons (524) 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 (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8081)
5. Microscopic 6. Pesticides (507) 6. PCB’s (Arochlors) (608/8081)
6. Macroscopic ZPesticides/PCB screen (508) 7. Methoprene (616) 2)
7, API y
aer 8. PCB as Decachlorobiphenyl (508A)
9. Herbicides (515)
8. Herbicides (EPA1978/8151)
9. Pesticides (SM18/6630)
Refrigerated? yes no a0 Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13) _
11. Carbamate Pesticides (531) 11. Glycols r.
Chlorinated:? yes no 12. Glyphosate (547) 12. Acid Extractables (625/8270)
13. Diquat (549) 13. Base Neutral Extractables (625/8270) 33
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
2. Turbidity 21. Alkalinity, as CaCO3 40. Antimony 60. Selenium
3. pH 22. Bromide 41. Arsenic 61. Silver : s O -
4. Conductivity 23. Bromate/Chlorate/Chlorite 42. Barium 62. Sodium | « co -
5. Corrosivity (temp: °C) 24. Chloride 43. Beryllium 63. Thallium] "C ===
6. BOD (5 day) 25. Cyanide 44. Boron 64. Vanadium t
7. Soluble BOD (5 day) 26. Fluoride 45. Cadmium 65. Zinc :•
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 NI 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
1sollids. Suspended 34. Phosphorus Total as P 53.Lead
71 TCLP-Metals
. Nollids. 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 58. Mercury 202
38. UV254 57 Molybdenum 74. TCLP-Volatiles
.19. Other:___________ 75.TCLP-BNA’s
. 58. Nickel n
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NYC-WTC_000025882
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