NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
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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)
lie Type (circle one): 8534,6838 (399,853s, 6536,397
1,Potable 3. Non Potable Treated Bottle #‘s: (821,500,
2. Non Potable 4. Other ,________________ ___ Chain of Custody? yes no
Time/Date Collected: 9/21/200 / 08+2 Comments:
Collected By: J■ Bolfon Agency Code: PWS#:_______ Source ID: .Type Descriptor
Collected From: Bill to:
Location’s/Individual’s Name 5 —_______________ Name/Company
Street________________________________________ Street________
City/St/Zip____________________________________ City/St/Zip
Identification of Source___________________________ Phone#:______ Fax#:
Collection Point__ 519S0_________ CA,CH, Bl? Check#: Amounts.
BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS . ORGANIC NONPOTABLE/SOLID ANALYSIS
Lab#:____________________ Lab#:_____ _ 22 7 / /
(circle tests) (circle tests) 00/0 —
1. Heterotrophic Plate 1.Trihalomethanes (524) 1 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 (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)
7.33 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) 1 2. 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)
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 3
5. Corrosivity (temp: °C) 24. Chloride 43. Beryllium 63. Thallium
6. BOD (5 day) 25. Cyanide 44. Boron 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 Ca
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
10plids, Suspended TCLP
34. Phosphorus Total as P 53.Lead
35. Phosphorus, Ortho as P 54 Magnesium 71 .TCLP-Metals
16. Solids, Total 72.TCLP-Pesticides
17. Solids, Total Dissolved 36. Sulfates 55 Manganese
37. Surfactants 56. Mercury 73. TCLP-Herbicides
18. Solids, Total Volatile 74. TCLP-Volatiles
19. Other________________ 38. UV254 57 Molybdenum 75.TCLP-BNA's
58. Nickel
NYC-WTC_000026439
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