NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
iv.com WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
(914) 593-5575
(3)
2
NYS-ELAP No. 10108
sSble Type (circle ono)
Time/Date Set:
A-B
Form A-70 (rev. 1/96)
: 1Potable 3. Non Potable Treated Bottle #’s: Bx 3
2. Non Potable 4. Other .. ... _............... ..... Chain of Custody? ves
Time/Date Collected: 4/4/200
Comments:
Collected By: AtAZz Agency Code:_____ PWS #:____________ Source ID: Type Descriptor:
Collected From: YACc ( — 7 1 " r
Bill to:
Location's/Individual's Name Nillyio.) /lScyoty Name/Company
Street .................................................... . .................................... Street ( e 1
City/St/Zip____________________________________________ City/St/Zip - ---------------------------------------------------------------------------
Identification of Source.... *....................... .... ................................. Phone#:____ _ _________________ Fax#:___________________•
Collection Point ____________ _____________ :______________ Aduei ■
_ ct • _______
Amoint
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BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS
Lab#: ..................... ................ Lab#_ -... 0..:
(circle tests) (circle tests) Z.207107 * SSI ■ . — d 0/01/087
1. Heterotrophic Plate 1. Trihalomethanes (524) / 1. Purgeable Halocarbons (624/8260)
Count (hemodialysis & ail others) ^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 <7.Pesticides/PCB screen (508) 7. Methoprene (616)
8. PCB as Decachlorobiphenyl (508A)
edr 9. Herbicides (515)
(10) Pesticides (525)
8. Herbicides (EPA1978/8151)
9. Pesticides (SMI8/6630)
10. Petroleum Hydrocarbon Scan (310-13)
Refrigerated? yesO 11. Glycols
11. Carbamate Pesticides (531)
Chlorinated:? ves.. 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 0 2 Alkalinity, as CaCO3 39. Aluminum 59. Potassium
2. Turbidity/" 40. Antimony 60. Selenium / cj
3. pH 22. Bromide 41. Arsenic 61. Silver * s
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 CaC03 46. Calcium, as CaCOa 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
Molids, Suspended 34. Phosphorus Total as P 53.Lead
71 TCLP-Metals
1Bolids, 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 Molybdenum
58. Nickel
75.TCLP-BNAs
NYC-WTC_000026115
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