NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
ster
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)
sMpie Type (circle one): Ss9, 8S0,000,159.*78
CPotable 3. Non Potable Treated Bottle #‘s: 987 4 8SS 7, SsSY, 8ss6 886 /
2. Non Potable 4. Other __ ____________________ Chain of Custody? yes no
Time/Date Collected: Q/2//200/ 1030 Comments:
Collected By: S, 4hwad Agency Code: PWS#:_______ Source ID: .Type Descriptor
Collected From: Bill to:
Location's/Individual’s Name _ VYh________ Name/Company
Street___________ :____________________________ Street________
City/St/Zip____________________________________ _
Identification of Source___________________________ Phone#:______ Fax#:
Collection Point_ 33450 CA,CH, Bl? Check#: Amounts.
BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS
Lab#:_____________________
(circle tests)
1. Heterotrophic Plate
(cirole tests) 2332
1. Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260)
Count (hemodialysis & all others) C2, 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. Pesticides (507) 6. PCB’s (Arochlors) (608/8081)
6. Macroscopic i 7Pesticides/PCB screen (508) 7. Methoprene (616)
7. 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151)
_________________________ 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. Add 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) 7?
pH 17. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB's (DEF)
18. Other_______________________ 18. Other_____ __________________ X.
INORGANIC ANALYSIS REQUESTED - Lab#:
(circle tests)
1. Color
2. Turbidity
3. pH
20. Acidity
21. Alkalinity, as CaCOa
22. Bromide
salaumanimydluk
40. Antimony
41. Arsenic
59. Potassium
60. Selenium
61. Silver
S
E
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 C.
I 8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOa 46. Calcium, as CaCOs CLP
: 9. Chemical Oxygen Demand 28. Nitrogen, Ammonia as N 47. Calcium, Ca+Z 66.Metals/CN oi
C.
; io. 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
10plids, Suspended
16. Solids, Total
33. Phenol
34. Phosphorus Total as P
35. Phosphorus, Ortho as P
52. Iron
53.Lead
54 Magnesium
TCLP
71 .TCLP-Metals §3
36. Sulfates 55 Manganese 72. TCLP-Pesticides
17. Solids, Total Dissolved 73. TCLP-Herbicides
18. Solids, Total Volatile 37. Surfactants 56. Mercury
57 Molybdenum 74. TCLP-Volatiles
19. Other:________________ 38. UV254
58. Nickel
75.TCLP-BNA‘s
NYC-WTC_000026437
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