NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
100
Ulestchester County
(e/DateSet:_____
WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
(914)593-5575 9<83 e
£
NYS-ELAP No. 10108
Form A-70 (rev. 1/96)
Sample Type (circle one): 8678,6683,8032,8600
0 Potable 3. Non-Potable Treated Bottle #‘s:lo76(, ? 3SS, 33,498 । o05*e 8623
2. Non-Potable 4. Other,____ Chain of Custody?____ yes .no
Time/Date Collected: 9/23/2001 _AM Comments:____________
Collected By: M. V'AcouB .Agency Code: _ .Source ID:. .Type Descriptor:
Collected From; Bill to:
Location’s/Individual’s Name. lli i t Y Qaseyor r Name/Company.
Street_______ _________ Street_______
City/St/Zip._____________ City/St/Zip____
Identification of Source____ Phone#: Fax#:
Collection Point. 2158 CA, CH, BI?. Check#: Amounts.
BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES
Lab#:__________________
(circle tests)
Lab#:
(circle tests)
23320 1. Purgeable Halocarbons (624/8260) •
1. Heterotrophic Plate 2 1. Trihalomethanes (524)
Count (hemodialysis & all others) C 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 (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 7Pesticides/PCB screen (508) 7. Herbicides (SM-18/6640; 8151)
7. API 8. PCB as Decachlorobiphenyl (508A) 8. Other Pesticides (SM-18/6630)
her:._________________ 9. Herbicides (515) 9. Petroleum Hydrocarbon Scan (310-13)
/ 10.Pesticides (525) 10. Glycols in Water
Refrigerated? yes____ no C 11. Carbamate Pesticides (531) 11. Acid Extractables (625/8270)
12. Glyphosate (547) 12. Base Neutral Extractables (625/8270)
Chtonnated?: _______ no 13. Diquat (549) 13. GC/MS Unknown Scan
14. Chlorination Disinfection Byproducts (551) 14. Purgeable Halocarbons (DEF)
Free Chionne Res:. mg/L 15. Haloacetic Acids (552) 15. Purgeable Aromatics (DEF)
16. Other Pesticides (SM-18/6630) 16. Pesticides (DEF)
Total Chlorine Res: .mg/L 17. Petroleum/Hydrocarbon Scan (310-13) 17. PCB’s (Arochlors) (DEF)
pH au
Ue
INORGANIC ANALYSES REQUESTED - Lab#:.
(circle tests)
rk~.
1. Color 20. Acidity 39. Aluminum 59. Potassium C
P
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 33
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 CaCOa 46. Calcium, as CaCOa 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-volatiles
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
a 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 74. TCLP-Volatiles
19. Other:____________ 38. UV254 57. Molybdenum 75. TCLP-BNA's
58. Nickel
N YC- WTC_000026451
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