NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
ster
vcom WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
(914) 593-5575
©
NYS-ELAP No. 10108
ge/Date Set: Form A-70 (rev.1/96)
Sample Type (circle one): 6/0(,0003,8S$1 @s*0 6549(654
GPotable 3. Non Potable Treated Bottle #s: 993/ 1364, +80 2 760, 0302-
2. Non Potable 4. Other —__________________ — Chain of Custody? yes no
Time/Date Collected: 2/21 1^60/ MS5 Comments:
Collected By: P, Gevtsil . Agency Code: _ Source ID: .Type Descriptor:
Collected From: P Bill to:
Location's/ndividual's Name 0 _ ________________ Name/Company
Street ___ ____________________________________ Street________
City/StZip______________________________________ _
Identification of Source_____ _________________ Phone#:______ Fax#:
Collection Point _________________________________
CA,CH, Bl? Check#: Amounts.
BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS
Lab#:____________________ Lab#:________ _
(circle tests) (circle tests) C .
1. Heterotrophic Plate 1.Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260)
Count (hemodialysis & all others) (2. 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. PCB’s (Arochlors) (608/8081)
6, Macroscopic
2
,6.1Pesticides (507)
Pesticides/PCB screen (508)
PCB as Decachlorobiphenyl (508A)
7. Methoprene (616)
8. Herbicides (EPA1978/8151)
6
Brothen_________________ Herbicides (515) 9. Pesticides (SM18/6630)
Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13)
Befrigerated? 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) C
16. Pesticides (SM18/6630) 16. Purgeable Aromatics (DEF)
pH 17. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB’s (DEF)
18. Other._______________________ . 18. Other ____________________
-S
1m —
INORGANIC ANALYSIS REQUESTED - Lab#:
(circle tests)
y
1. Color 20. Acidity 39. Aluminum 59. Potassium
2. Turbidity 21. Alkalinity, as CaCOs 40. Antimony 60. Selenium C
3. pH 22. Bromide 41. Arsenic 61. Silver
4. Conductivity 23. Bromate/Chiorate/Chlorite 42. Barium 62. Sodium S
5. Corrosivity (temp:. °C) 24. Chloride 43. Beryllium
44. Boron
63. Thallium
so
6. BOD (5 day) 25. Cyanide 64. Vanadium
C
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
R
11. Total Organic Carbon
12. Total Organic Halides
13. Solids, Percent (%)
30. Nitrogen, Nitrite as N
31. Nitrogen, Total Kjeldahl as N
32. Oil an Grease
49. Chromium, Hexavalent
50.Cobalt
51. Copper
68.Semi-violatiles
69. Pesticides/PCB’s
70. Disk Deliverables
+
. Solids, Settleable 33. Phenol 52. Iron TCLP
. Solids, 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
57 Molybdenum 74. TCLP-Volatiles
19. Other:___________ 38. UV254 75. TCXP-BNA’s
58. Nickel
NYC-WTC_000026435
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