NYC 9/11 Public Portal Document
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ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
ster
.com WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
(914) 593-5575
09
NYS-ELAP No. 10108
GgeDate Set: Form A-70 (rev.1/96)
Sample Type (circle one): 4s32,652S70233,004,5700, 1320
IJPotable 3. Non Potable Treated Bottle #‘s: 454 3,8°30SS 3/, SSI 2/
2. Non Potable 4. Other Chain of Custody? yes no
Time/Date Collected: ___________________ _ Comments:
Collected By: hossnue Ps Agency Code: _ Source ID: .Type Descriptor
Collected From: Bill to:
Location’s/Individual’s Name
Street________________
On 5 Name/Company _
Street________
City/St/Zip . _
Identification of Source * ------‘ ■ 6:
Phone#:______ Fax#: Br5 ■
Collection Point nei 44sso u &
CA,CH, BI?_ Check#: Amounts, '
2. 4 4.
■ 3. =
BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS
Lab#:____________________
(circle tests)
1. Heterotrophic Plate
Lab#:
(circle tests) 225
1.Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260) -
Count (hemodialysis & all others) 12.olatile 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) 8. Herbicides (EPA1978/8151)
8. Other_______________ 9. Herbicides (515) 9. Pesticides (SM18/6630)
< *10. Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13)
Refrigerated? yes no * -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
(Solids, Settleable 33. Phenol 52. Iron
“Solids, Suspended TCLP
34. Phosphorus Total as P 53.Lead
454 Magnesium 71 .TCLP-Metals
16. Solids, Total 35. Phosphorus, Ortho as P
17. Solids, Total Dissolved 36. Sulfates 55 Manganese 72.TCLP-Pesticides
73. TCLP-Herbicides
18. Solids, Total Volatile 37. Surfactants 56. Mercury
74. TCLP-Volatiles
19. Other:________________ 38. UV254 57 Molybdenum 75. TCLP-BNA's
58. Nickel
NYC-WTC_000026445
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