NYC 9/11 Public Portal Document
WPP Sssetanl 24598428190 703217a
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gime/Date Set:
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/ ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
(914) 593-5575 NYS-ELAP No. 10108
Form A-70 (rev. 1/96)
Vmple Type (circle one): 9S00, 092,1140,797%, 149 2
1. Potable 3. Non-Potable Treated Bottle #‘s: 0034, 8ebi, 8668 f 664, 8062 , sS8
2. Non-Potable 4. Other___________________________ Chain of Custody? yes .no
Time/Date Collected:. Q/25200D * Comments:_____
Collected By: 1.An/NNK#LAaencv Code:
PWS#: .Source ID:_______Type Descriptor.
Collected From: / Bill to:
Location's/individuar's Name. Hilveew Cose+vory Name/Company
Street_________________ _ ____________________________ Street
City/StZio _______________ ___________________ ___ Ciy/SvZip
Identification of _________________________ _ ______ ______ Phone#: Fax#:.
Collection Point 613 CA, CH, BI? Check#:. Amounts
BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES
Lab#:______ ______________
(circle tests)
1. Heterotrophic Plate ■’
Count (hemodialysis & all others)
2. Coliform P/A (public Supplies)
".
“=22447
2, Volatile Halocarbons (524). .
{‘3, Volatile Aromatics (524)
1. Purgeable Halocarbons (624/8260)
2. Purgeable Aromatics (624/8260)
3. Acrolein & Acrylonitrile (624)
3. Coliform MPN (priy well, raw, stp) 4. Total Trihalomethane Potential (510) 4. Phthalates (606/8060)
4. Fecal Coliform (all samples) 5. Microextractabies (504) 5. Organochlorine Pesticides (608/8080) '
5. Microscopic f ' 6. Pesticides (507) . 6. PCB’s (Arochlors) (608/8080)
6. Macroscopic 117.7 Pesticides/PCB screen (508) 7. Herbicides (SM-18/6640; 8151)
7.AP! 8. PCB as Decachlorobiphenyl (508A) .8. Other Pesticides (SM-18/6630)
^^ther:= 9. Herbicides (515) ; 9. Petroleum Hydrocarbon Scan (310-13)
i ‘10. Pesticides (525), . 10. Glycols in Water
Hefrigerated? yes no 11. Carbamate Pesticides (531) 11. Acid Extractables (625/8270) ,*
12. Glyphosate (547) 12. Base Neutral Extractables (625/8270) =:
Chlorinated?: .yes no 13. Diquat (549) 13. GC/MS Unknown Scan
14. Chlorination Disinfection Byproducts (551) 14. Purgeable Halocarbons (DEF)
Free Chlorine Res: smg/L 15. Haloacetic Acids (552) 15. Purgeable Aromatics (DEF)
16. Other Pesticides (SM-18/6630)' 16. Pesticide/(DEF)
Total Chlorine Res: mg/L 17. Petroleum/Hydrocarbon Scan (310-13) 17. PCB’s (Arochlors) (DEF)
pH
INORGANIC ANALYSES REQUESTED - Lab#: pyt •
(circle tests)
! C-i
1. Color 20. Acidity 39. Aluminum . 59. Potassium C -
2. Turbidity 21. Alkalinity, as CaCO3 40. Antimony 60. Selenium/// c
3. pH 22. Bromide 41. Arsenic 61.Silver ; ty
4. Conductivity 23. Bromate/Chlorate/Chlorite 42. Barium 62. Sodium 1 /
5. Corrosivity (temp: °C) 24. Chloride 43. Beryllium 63. Thallium i
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 CaCO3 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_______
14, Solids, Settleable 33. Phenol 52. Iron ISLE
Golids, Suspended 34. Phosphorus. Total as P 53. Lead 71. TCLP-Metals
TSolids, 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
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NYC-WTC_000026612
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