NYC 9/11 Public Portal Document
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ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
>v.com WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595 J
(914) 593-5575 h / 1
NYS-ELAP No. 10108
Time/Date Set QC Cd / 3 . vwl . /A.u
............. ............................ .... .... .......... ....... .
Form A-70 (rev. 1/96)
mple Type (circle one): ef
'. . 2 d J
1.Potable ;3. Non Potable Treated Bottlers: ? - '
- - i 7. •____ 216
2. Non Potable 4. Other Chain of Custody? _ yes no S _ ', 1
Time/Date Collected:
Collected By: +
—448/201/ 442
Agency Code:
Comments:
PWS #:________ Source ID: Type Descriptor:
Collected From: “8 ' C L Bill to; .
p
Location’s/Individual’s Name _& Name/Company
Street _ —. Street
City/St/Zip _ City/St/Zip _
Identification of Source *____________________ Phone#: : Fax#:
Collection Point 285 SQ CA,CH, Bl? Check#:
—.. m.. .. ... u................... nrrnir
Amounts________
BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SgOD ANALYSIS
Lab#:
(circle tests)
1. Heterotrophic Plate
(&k“aws— Z-Z—4Ht
1. Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260)
Count (hemodialysis & all others) 22Volatile 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) oous
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4. Fecal Coliform (all samples) 5. Microexfractables (504) 5. Organochlorine Pesticides (608/8081) S
5. Microscopic 6. Pesticides (507) 6. PCB’s (Arochlors) (608/8081) siia
6. Macroscopic Z.Pesticides/PCB screen (508) 7. Methoprene (616)
2
7AP
W er. —
8. PCB as Decachlorobiphenyl (508A)
i. Herbicides (515) ?
8. Herbicides (EPAI 978/8151)
9. Pesticides (SM18/6630)
j
Refrigerated? ‘ yes no .0 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 (SM 18/6630) 16. Purgeable Aromatics (DEF)
pH 17. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB's (DEF)
18. Other: ; 18. Other:■
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INORGANIC ANALYSIS REQUESTED - Lab#: / 4e
• 2
(circle tests)
1. Color 20. Acidity 39. Aluminum 59. Potassium
2. Turbidity 21. Alkalinity, as CaGOa 40. Antimony 60. Selenium ,
3. pH 22. Bromide 41. Arsenic 61. Silver f/ / ,
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
26. Fluoride 45. Cadmium
7. Soluble BOD (5 day)
8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCO3 46. Calcium, as CaCOa ■:
CLP-------------- - ----; :-
65. Zinc ' : '.
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
411. 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
iSolids. Suspended 34. Phosphorus Total as P 53.Lead
Solids, Total 71 .TCLP-Metals
35. Phosphorus, Ortho as P 54 Magnesium
72. TCLP-Pesticides
-17. Solids, Total Dissolved 36. Sulfates 55 Manganese
37. Surfactants 56. Mercury / •
73. TCLP-Herbicides
18. Solids, Total Volatile
74. TCLP-Volatiles
19. Other: _ 38. UV254 57 Molybdenum
58. Nickel . ' ' 75. TCLP-BNA’s
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NYC-WTC_000026110
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