NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
ster
com WESTCHESTER COUNTY LABORATORIES AND RESEARCH
-2 Dana Road, Valhalla, New York 10595
(914) 593-5575 Deue
NYS-ELAP No. 10108
Time/Date Set: Form A-70 (rev.1/96)
sRpietypo (circle one): 8432-,00* 2,1103,0236, (tr 1, eys
1.Potable 3. Non Potable Treated
Bottle #s: 8704,6150, 664 0, 8913,6730____
2. Non Potable 4. Other ______________ Chain of Custody? yes no
Time/Date Collected: 9/20/200/ 4 Comments:
A
Collected By: 7 A— Ao AA ( i Agency Code: _ _ Source ID: Type Descriptor:
Collected From: »/ Bill to:
Location’s/Individual’s Name. AaobyrewlCseruo/r Name/Company _
Street__________________________________________ Street________
City/St/Zip________ '__________ ;_________________ __ City/St/Zip
Identification of Source " Phone#: ______ Faxif:
Collection Point te-nt
__________ *_
B158 CA.CH, Bl? Check#: Amounts.
" 4.0 ---===----=======2=
BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS
I ah#_______ ‘** Lab#:______________________
(circle tests) 14/t. (circle tests)
1. Heterotrophic Plate 1. Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260)
Count (hemodialysis & all others) ‘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 (privwell, raw,stp) 4. Total Trihalomethane Potential (510) 4. Phthalates (625/8270)
4. Fecal Conform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8081) els
5. Microscopic 6. Pesticides (507) 6. PCB’s (Arochlors) (608/8081) 57"
6. Macroscopic (7.Pesticides/PCB screen (508) 7. Methoprene (616)
7P 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151) {
__________
( Herbicides (515) 9. Pesticides (SM18/6630) s '
Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13),-
Refrigerated? yes no
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)
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 (SM18/8630) 16. Purgeable Aromatics (DEF)
pH 17. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB’s (DEF)
18. Other_______________________ 18. Other_______________________ 2
INORGANIC ANALYSIS REQUESTED - Lab#:
(circle tests)
1. Color 20. Acidity
22 >50 39. Aluminum ) • 59. Potassium
2. Turbidity 21. Alkalinity, as CaCO3 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 CaCO3 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-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. Soilds, Settleable 33. Phenol 52. Iron
TCLP
(Sollids. Suspended 34. Phosphorus Total as P 53.Lead
71 .TCLP-Metals
WSolids. 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
57 Molybdenum 74. TCLP-Volatiles
19. Other___________ 38. UV254
58. Nickel
75. TCLP-BNA’s
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NYC-WTC_000026696
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