NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
Ulestchester County (914) 593-5575 NYS-ELAPNo. 10108
Time/DateSet:_____ __________________________________ Form A-70 (rev. 1/96)
Subiple Type (circle one): 860 1 F6Q , 6s4b , 6672-.PF6 8678, 8632
1,Potable 3. Non-Potable Treated Bottle #s:8oSS, 0403,60S 2,0030
2. Non-Potable 4. Other , _______ __ __________ Chain of Custody? yes .no
Time/Date Collected: 9/22/200/ _ qAn— Comments:
Collected By:. M-YACouR_ _Agency Code: PWS #:_________ Source ID: Type Descriptor:
Collected From: • Bill to:
Location's/individual's Name_ Hallview) Name/Company
Street ........................ ........................................... .......... ......... Street__________
City/St/Zip ________________________________ City/St/Zip_______
Identification of Source,_____________________________ ____ Phone#:_ Fax#:,
Collection Point, 8158 _________ CA, CH, BI? Check#: Amounts,
BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES
Lab#:
(circle tests)
_________________ lab.: ---- 92210
(circle tests) . I I
1. Heterotrophic Plate Trihalomethanes (524) I 1. Purgeable Halocarbons (624/8260) -
Count (hemodialysis & all others) Volatile 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 (606/8060)
4. Fecal Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8080)
5. Microscopic 6. Pesticides (507) 6. PCB*s (Arochlors) (608/8080)
6. Macroscopic C 7.Pesticides/PCB screen (508) 7. Herbicides (SM-1 8/6640; 8151)
7. API 8. PCB as Decachlorobiphenyl (508A) 8. Other Pesticides (SM-18/6630)
8ther: 9. Herbicides (515) 9. Petroleum Hydrocarbon Scan (310-13)
( 10. Pesticides (525) 10. Glycols in Water
Refrigerated? yes____ no 11. Carbamate Pesticides (531) 11. Acid Extractables (625/8270)
12. Glyphosate (547) 12. Base Neutral Extractables (625/8270)
Chlonnated?: ves_____ no 13. Diquat (549) 13. GC/MS Unknown Scan
14. Chlorination Disinfection Byproducts (551) 14. Purgeable Halocarbons (DEF)
Free Chiorine Res:. mg/L 15. Haloacetic Acids (552) 15. Purgeable Aromatics (DEF)
16. Other Pesticides (SM-18/6630) 16. Pesticides (DEF)
O
C
Total Chlorine Res: mg/L 17. Petroleum/Hydrocarbon Scan (310-13) 17. PCB’s (Arochlors) (DEF)
pH
INORGANIC ANALYSES REQUESTED - Lab# S
(circle tests)
1. Color 20. Acidity 39. Aluminum 59. Potassium e
2. Turbidity
3. pH
21. Alkalinity, as CaCOs
22. Bromide
40. Antimony
41. Arsenic
60. Selenium
61. Silver
o
4. Conductivity 23. Bromate/Chlorate/Chlorite 42. Barium 62. Sodium
5. Corrosivity (temp: .°C) 24. Chloride 43. Beryllium 63. Thallium Cw
6. BOD (5 day) 25. Cyanide 44. Boron 64. Vanadium
7. Soluble BOD (5 day) 26. Fluoride 45. Cadmium 65. Zinc__________
S
G-
8. Carbonaceous BOD (5 day)
9. Chemical Oxygen Demand
10. Dissolved Oxygen
27. Hardness, Total as CaCOs
28. Nitrogen, Ammonia as N
29. Nitrogen, Nitrate as N
46. Calcium, as CaCOs
47. Calcium, Ca*2
48. Chromium, Total
CLP
66. Metals/CN
67. Volatiles
I
11. Total Organic Carbon 30. Nitrogen, Nitrite as N 49. Chromium, Hexavalent 68. Semi-volatiles 0
12. Total Organic Halides 31. Nitrogen, Total Kjeldahl as N 50. Cobalt 69. Pesticides/PCB’s
13. Solids, Percent (%) 32. Oil and Grease 51. Copper 70. Disk Deliverables
14Solids, Settleable 33. Phenol 52. Iron ISLE
Colids, Suspended 34. Phosphorus. Total as P 53. Lead 71. TCLP-Metals
16. Solids, 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 75. TCLP-BNA’s
AS = 58. Nickel
NYC-WTC_000026434
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