NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
Westchester
dinngovcom WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
(914)593-5575
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NYS-ELAP No. 11s
ime/Date Set: Form A-70 (rev. 1/96)
Sample Type (circle one):
Bottle #s? « ""
88875.
1. Potable % 3. Non Potable Treated -- ----- —
v ______ J
2.Non Potable 4. Other Chain of Custody? yes no } ■
Time/Date Collected: 202
1/54//.. — Comments:
Collected By. ==s. Agency Code:..... PWS ______ __ _ _ Source ID Type Descriptor:..
Collected From: Bill to:
Location’s/Individual
,41 ’s Name A
J 1. A_ PPP
5 , Name/Company
Street .. L/......../) 4 I Alle _ LAo__ ,..... ... Street---------- —
City/StZip Ua /he Ha , - 1 0 595 City/St/Zip _
Identification of Source _.... _.... _%_____ ■ Phone#:. Fax#:
Collection Point _ _____ CA,CH, Bl? _.. Check#: Amounts....
9999
BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS
i Lab# ====== Lab#: -..... —Cn2
(circle tests) (circle tests)
1. Heterotrophic Plate 1 Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260)
Count (hemodialysis & all others) 2] Voiatile 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)
.APIMacroscopic
8. Other:_______ _ ___________
(7, Pesticides/PCB screen (508)
Us PCB as Decachlorobiphenyl (508A)
7. Methoprene (616)
8. Herbicides (EPA1978/8151)
9. Herbicides (515) 9. Pesticides (SM18/6630)
fo Pei ! ( . 10. Petroleum Hydrocarbon Scan (310-13)
Refrigerated?yes___ no <1t 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)
ree Chlorine Res: mg/L 14. Chlorination Disinfection Byproducts (551) 14. GC/MS Semivolatile Unknown Scan
15. Haloacetic Acids (552) 15. Purgeable Halocarbons (DEF)
Total Chlorine Res:... . mg/L 16. Pesticides (SM18/6630) 16. Purgeable Aromatics (DEF)
PH 17. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB’s (DEF)
18. Other: 18. Other:■
1...
INORGANIC ANALYSIS REQUESTED - Lab#:
(circle tests)
1. Color 20. Acidity
/39. Aluminum ybve,
1 7 / 59> Potassium ;
/l /
2. Turbidity 21. Alkalinity, as CaCO3 / 40. Antimony 60. Selenium !
3, pH 22. Bromide
23. Bromate/Chlorate/Chlorite
| 41 Arsenic
( 42 Barium
61. Silver
4. Conductivity 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 Ign 45,Cadmium
46. Calcium, as CaCOa
. 65/Zinc—
s d i 1 * i "-.'.-: ! 1 (5 dm 1 27. Hardness. Total as CaCO3 MP
? GmnOma Demand 28 Nitrogen, Airronia as H 47:Calcium, Ca "2 no MIAtPN
48.Chromium, Total
10. Dissolved Oxygen
1 Ialompasent )
:9 Niticon tor . - N
0 Nittogi it. r tit ; N
1 Narogen ■-• di: . i;
49. Chromium, Hexavalent
,50.Cobalt
t/. V allies
66 Smm* -vd.-Jjl.-
12. Total Organic Halides 69 Fectichet’Ci
13. Solids, Percent (%) 32 Oil an Grease 51 .-Copper . DS tolivanzidne
1. Solids, Settleable -33, Phenol 52 1ron 20217140777 ITCLP
.5, Solids, Suspended 34. Phosphorus Total as P l 53.Lead /10 P Me Li!.
35. Phosphorus, Ortho as P 54 Magnesium 0
17, Solids. Total Dis olved I
16. Solids, Total
18. Solids. Total Volatile r
36. Sulfates
37. Surfactants
| 55; Manganese
( 56 Mercury
l ■: * i -Purda ploe
A G Pu kbicios
A IC ! -Veatilcr
19. Other G2.//s
777
38.UV254 * 57 Molybdenum
s 58. Nickel
75. TCLP MNR
NYC-WTC_000026586
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