NYC 9/11 Public Portal Document
Wekg6stsm ENVIRONMENTAL SERVICES SAMPLE SUBMISSIONFORMA 3
WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
.
(914) 593-5575
NYS-ELAP No. 10108
Time/Date Set: Form A-70 (rev.1/96)
ppleType (circle one):
1. Potable 3. Non Potable Treated Bottle #’s:
2. Non Potable 4. Other ___ _______________________ Chain of Custody? yes no
Time/Date Collected: _ 9/14/200' /0;62 P Comments:
Collected By:. H.fATC . Agency Code: _ Source ID: .Type Descriptor:
Collected From: Bill to:
Location’s/ndividual’s Name MyookU Name/Company _
Street_____ ___________ Street________
City/St/Zip_____________ City/St/Zip
Identification of Source Phone#:______ Fax#:
Collection Point 4SS0
CA,CH, Bl? Check#: Amounts.
BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS
Lab#:____________________
(circle tests)
1. Heterotrophic Plate Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260)
chP, Volatile Halocarbons (524)
Count (hemodialysis & all others)
2. Coliform P/A (public supplies)
3. Coliform MPN (priv well, raw, stp)
o Volatile Aromatics (524)
4. Total Trihalomethane Potential (510)
2. Purgeable Aromatics (624/8260)
3. Acrolein & Acrylonitrile (624)
4. Phthalates (625/8270)
4. Fecal Coliform (aS samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8081)
5. Microscopic 6. Pesticides (507) 6. PCB's (Arochlors) (608/8081)
6. Macroscopic CPesticides/PCB screen (508) 7. Methoprene (616)
7. API 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151)
_________ 9. Herbicides (515) 9. Pesticides (SM18/6630)
Reifgerated? yes no (10 Pesticides (525) 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
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*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
tolids. 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
19. Other________________ 38. UV254 57 Molybdenum 74. TCLP-Volatiles
75.TCLP-BNA’S
58. Nickel
NYC-WTC_000026060
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