NYC 9/11 Public Portal Document
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ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ]
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i iv.com 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) .....
C: 8A< -08)
Sample type (circle one):
(LPotable 3. Non Potable Treated Bottle #‘s: 1“112,5 “V. LA t 4* P- so
2. Non Potable 4. Other_________________ Chain of Custody? _ yes no
Time/Date Collected: 9/9/2001 1^0^ Comments:
Collected By: —Kagz— Agency Code: _ Source ID: Type Descriptor:
Collected From: Bill to:
Location’s/Individual’s Name M A Name/Company _
Street________________ _______________ Street________
City/St/Zip__________ __ _______________ City/St/Zip _
Identification of Source __________ _ 'Phone#: .43 Fax# ff ...
Collection Point 2 (“f/ 5
2 OV 4 CA,CH,Bi?t
28007 aa/tak— Check AmounisEp
; * /t. . 429605
7 . 0.. Wupoo
BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS
Lab#:____________________ Lab#:_______ —________ —
(circle tests) (circle tests)
1. Heterotrophic Plate 1. Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260)
Count (hemodialysis & all others) 2.2Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260)
2. Coliform P/A (public supplies) 3. Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624)
3. Coliform MPN (privwell, 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) ,
7.6
8. OMer:__________________
.PCB as Decachlorobiphenyl (508A)
. Herbicides (515)
8. Herbicides (EPA1978/8151) /
9. Pesticides (SM18/6630)
Refrigerated? yes no ) Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13)
1.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)
3303
1. Color 20. Acidity 39. Aluminum ,__ 59. Potassium
2. Turbidity 21. Alkalinity, as CaCOs 40. Antimony 60. Selenium
3. pH 22. Bromide 41. Arsenic 2 61. Silver
4. Conductivity 23. Bromate/Chlorate/Chlorite 42. Barium a 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
19blids, Suspended 34. Phosphorus Total as P 53.Lead
71 TCLP-Metals
16. Solids, Total 35. Phosphorus, Ortho as P 54 Magnesium
72.TCLP-Pesticldes
17. Solids, Total Dissolved 36. Sulfates 55 Manganese
73. TCLP-Herbicides
. 37. Surfactants 56. Mercury
18. Solids, Total Volatile
19. Other: . _ ___________ 38. UV254 57 Molybdenum 74. TCLP-Volatiles
75.TCLP-BNA’S
58. Nickel
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NYC-WTC_000026265
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