NYC 9/11 Public Portal Document
TOr ENVIRONMENTAL SERVICES SAMPLE SUBMISSIONFORM,
WESTCHESTER COUNTY LABORATORIES AND RESEARCH "
com
2 Dana Road, Valhalla, New York 10595 1Pg
Time/Date Set:
(914) 593-5575
NYS-ELAP No.Horos
Form A-70 (rev.1/96)
pple Type (circle one):
1. Potable 3. Non Potable Treated Bottle _ _______
2. Non Potable 4. Other ___________ Chain of Custody? yes no
Time/Date Collected: _ 1/7/200/ //42 A Comments:
Collected By:. MAGs) Agency Code: _ Source ID: .Type Descriptor
Collected From: Bill to:
Location’s/ndividual’s Name. Broy Name/Company
Street_____ ___________________ Street________
City/St/Zip___________________ _ City/St/Zip
Identification of Source - Phone#:______ Fax#:
Collection Point _SO
CA,CH, Bl? Check#: Amounts.
BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS
Lab#:_____________________ Lab#:____
(circle tests) (circle tests)
1. Heterotrophic Plate Trihalome 1. Purgeable Halocarbons (624/8260)
Count (hemodialysis & all others) Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260)
2. Coliform P/A (public supplies) 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 Pesticides (507) 6. PCB’s (Arochlors) (608/8081)
6. Macroscopic Pesticides/PCB screen (508) 7. Methoprene (616)
7. API 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151)
__________________________ 9. Herbicides (515) 9. Pesticides (SM18/6630)
Refrigerated?yes no (10Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13)
11. Carbamate Pesticides (531) 11. Glycols
Chlorinated:? yes no 12. Glyphosate (547) 12. Add 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 Adds (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
4. Conductivity 23. Bromate/Chlorate/Chiorite 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*2 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
TCLP
15. Solids, Suspended 34. Phosphorus Total as P 53.Lead 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
38. UV254 57 Molybdenum 74. TCLP-Volatiles
19. Other________________ 75.TCLP-BNA‘s
58. Nickel
NYC-WTC_000026059
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