NYC 9/11 Public Portal Document
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ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
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(914) 593-5575 NYS-ELAP No. 10108
ge/Date Set: ______________________ _ Form A-70 (rev. 1/96)
wmpleType (circle one): 8039, 8035,8034,04/ < 0058
1 Potable 3. Non-Potable Treated Bottle #8698,8873, 8052,839 8635 863
2. Non-Potable 4. Other, ________________ Chain of Custody? yes .no
Time/Date Collected: 1/2 4/200/ Isol'S
Comments:.____
Collected By: S . __ _____________ Agency Code: .Source ID:_______ Type Descriptor:.
PWS #:_________
Collected From: Bill to:
Location’s/ndividual’s Name. Bookly Name/Company
Street________ _________ Street_________ _
___________________ _
Identification of Source- ,
DePIAF# Phone#: Fax#:
Collection Point " 24290 28431 CA, CH, Bl? Check#: Amounts.
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BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES
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Lab#:
. (circle tests). . ■
■ . ■ ■ Lab#:
(circle tests) —AS : " 88p*
1.. Purgeable Halocarbons (624/8260)
1 Heterotrophic Plate 1. Trihalomethanes (524)
Count (hemodialysis’& all others) . 2.4 Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260)it
2. Coliform P/A (public supplies) s 3, Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624) :
3. Coliform MPN (privwell, raw, stp) 4. Total Trihalomethane Potential (510) 4. Phthalates (606/8060) sj
4. Fecal Coliform jail samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8080) y
5. Microscopic . , ' 6. j Pesticides (507) 6. PCB’s (Arochlors) (608/8080) S
6. Macroscopic . ’ ’ ( Jk Pesticides/PCB screen (508) 7. Herbicides (SM-18/6640; 8151)
7. API 1 : 8. PCB as Decachlorobiphenyl (508A) 8. Other Pesticides (SM-18/6630) 2
8Other: - _______ 9. Herbicides (515) 9. Petroleum Hydrocarbon Scan (31 0-13)
*. .
( 10. Pesticides (525) 10. Glycols in Water 4
Refrigerated? yes_____ no 11. Carbamate Pesticides (531) .11. Acid Extractables (625/8270) —
12. Glyphosate (547) 12. Base Neutral Extractables (625/8270) *
Chionnated?: yes no 13. Diquat (549) 13. GC/MS Unknown Scan P*
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
INORGANIC ANALYSES REQUESTED - Lab#:.
(circle tests)
1. Color 20. Acidity
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39. Aluminum -=
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59. Potassium; (
C
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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 •
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 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
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 TCLP
Colids, Suspended 34. Phosphorus. Total as P 53. Lead 71. TCLP-Metals
To. 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
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NYC-WTC_000026617
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