NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
tchester
VCOII WESTCHESTER COUNTY LABORATORIES AND RESEARCH 7
2 Dana Road, Valhalla, New York 10595
12222.(914)593-5575
NYS-ELAP No. 10108
-e/Date Set: Form A-70 (rev. 1/96)
sMpleType (circle one):
2109-F/uC
PFGPPAm
034 1 ,F1%, - ,31 > ,19 197,
'' 1. Potable./ 3. Non Potable Treated Bottle #‘s:__ )____ _ __ ____ _______ __ __ _ __________ . .
2. Non Potable 4. Other Chain of Custody?___ yes____ no
___
Time/Date Collected: -2.5 Comments:
Collected By: l 0.2........... Agency Code:___ PWS #: __ Source ID: Type Descriptor:
Collected From: Bill to:
Location’s/Individual’s Name... ......... .... Name/Company
Street _ _6 LA_NC___ Street _... __
City/SUZip _ . ............. Le— 2./ _ City/St/Zip
Identification of Source.—-
Phone#: . Fax#:
Collection Point _CAS . Let+___ b/ CA,CH, Bl? _ Check#: Amounts_
BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGAP NONPOIABLNS0L H? ANALYSIS
Lab#:..... ....... -__ _______ _ _____ _
(circle tests)
Lab#:___
.(circle tests) 2275t
1. Heterotrophic Plate 1—Trihalomethanes (524) ’ 1. Purgeable Halocarbons (624/8260)
Count (hemodialysis & all others) (2.4olatile 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)
- Microscopic 6. Pesticides (507) 6; PCB’s (Arochlors) (608/8081)
Macroscopic / 7.Pesticides/PCB screen (508) z. Methoprene (616)
7_ 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151)
8 er:___ ___ ____ . . . 9. Herbicides (515) 9. Pesticides (SM18/6630)
F10. Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13)
Refrigerated?____ yes _ h'>
11 Carbamate Pesticides (531) 1 , Glycols
Chlorinated:? . ....... yes no 12. Glyphosate (547) 12. Acid Extractables (625/8270)
Free Chlorine Res:._ ur:!
113. Diquat (549) __17000
14. Chlorination Disinfection Byproducts (551)
13. Base Neutral Extractables (625/8270)
14. GC/MS Semivolatile Unknown Scan
15. Haloacetic Acids (552) 15. Purgeable Halocarbons (DEF)
Total Chlorine Res: _ mg/L
16. Pesticides (SMI8/6630) 16. Purgeable Aromatics (DEF)
pH _ 17. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB’s (DEF)
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18. Other:___ __ __________________ ___ 18. Other:
INORGANIC ANALYSIS REQUESTED - Lab#:
(circle tests)
1. Color 20. Acidity
. 21. Alkalinity, as CaCO3
39) Aluminum
40. Antimony
259. Potassium .
60. Selenium
2. Turbidity
3. pH 22. Bromide 141. Arsenic — 61. Silver
4. Conductivity 23. Bromate/Chlorate/Chlorite 42, Barium 62. Sodium 1
5. Corrosivity (temp:_ _ °C) 24. Chloride 43/ Beryllium 63. Thallium 5
6. BOD (5 day) 25. Cyanide 44. Boron 64.JVanadium 5 :
7. Soluble BOD (5 dav) 26. Fluoride (45)Cadmium 1 65/Zinc: kA
8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOs 46. Calcium, as CaCOa
(47.Calcium, Ca *2
I CLP
9. Chemical Oxygen Demand 28. Nitrogen, Ammonia as N 66. Metals/CN
29. Nitrogen, Nitrate as N / 48 Chromium, Total
10. Dissolved Oxygen 67. Volatiles
11. Total Organic Carbon 00 Niljog I. MJilna -s P 49. Chromium, Hexavalent i.;. Semi viridiec
60X obalt
011 an Grease
Percent (%) Iee -33,32, Phenol
ids. Settleable
“.3, SSololids,
12. Total Organic Halides :1. Nite it -i . 1a i F:-. li r s s
ee Lead Zopper 51.
1 1 csir isleet I T
70. Disk Deliverables
(olids. Suspended 34. Phosphorus Total as P
52. Iron
53.
ITCLP_
71 .TCLP-Metals
To. Solids, Total . 35. Phosphorus, Ortho as P 54 Magnesium
17. Solids, Total Dissolved 36.
37. Sulfates esenee. 55. Mercury _
Surfactants
Manganese
72.TCLP-Pesticides
73. TCLP-Herbicides
19. Other SyTta -38.UV254 57
18. Solids, Total Volatile
Molybdenum
58,NickelI
56
74. TCLP-Volatiles .
Pi...
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NYC-WTC_000026021
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