NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
ster WESTCHESTER COUNTY LABORATORIES AND RESEARCH
iv.com
2 Dana Road, Valhalla, New York 10595
(914) 593-5575 A
NYS-ELAP No. 10108
yOateSet: CC Sd Axl. 4.72 wla LC Form A-70 (rev.1/96)
Sample Type (circle one): 6962, 8753,89/3*37,6608,620
(1.Potable 3. Non Potable Treated Bottle #s: 00138975,8003 6699 %70/,87u/
2. Non Potable 4. Other ____________________ Chain of Custody? yes no
Time/Date Collected: zad / - (825 Comments:
Collected By: J Pol tA Agency Code: _ Source ID: .Type Descriptor
Collected From: Bill to:
Location’s/ndividual’s Name plolatak Name/Company
Street Street________
City/St/Zip *4 City/St/Zip_____
Identification of Source - * - 3 : •. __ D&PLADA ,; Phone#: Faxi:
' 290 7 2,
Collection Point ...4 aBu Q $D
Fese
BACTERIOLOGICAL ANALYSIS
‘ i CA,CH, BI? Check#: Amounts.
ORGANIC POTABLE ANALYSIS f ORGANIC NONPOTABLE/SOLID ANALYSIS
l ah#- ~ ’ *****
Lab#:____________________
(circle tests) r (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) .olatile Aromatics (524) 3. Acrolein & Acrylonitrile (624)
3. Coliform MPN (priv well, raw, stp) 4. Total Trihalomethane Potential (510) 4. Phthalates (625/8270)
4. Fecal Conform (an samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8081) ,
5. Microscopic 6. Pesticides (507) 6. PCB’s (Arochlors) (608/8081) ft
6. Macroscopic “7.Pesticides/PCB screen (508) 7. Methoprene (616) ’n
Gr— -8. PCB as Decachlorobiphenyl (508A)
i. Herbicides (515)
1 Pesticides (525)
8. Herbicides (EPA1978/8151)
9. Pesticides (SM18/6630)
1D Petroleum Hydrocarbon Scan (310-13) i
Refrigerated? yes no -1. 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:. _____ _ 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 (SM18/6630) 16. Purgeable Aromatics (DEF)
pH 17. Petroteum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB’s (DEF)
18. Other._______________________ 18. Other_____________________ __
INORGANIC ANALYSIS REQUESTED - Lab#:
(circle tests)
1. Color 20. Acidity
)255) 39. Aluminum 59. Potassium
2. Turbidity 21. Alkalinity, as CaCO3 40. Antimony 60. Selenium
3. pH 22. Bromide 41. Arsenic 61. Silver j . .2
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 I
8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCO3 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-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, Solids, Settleable 33. Phenol 52. Iron
TCLP
(Solids, 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
57 Molybdenum
74. TCLP-Volatiles
19. Other________________ 38. UV254
75.TCLP-BNAs
58. Nickel
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NYC-WTC_000026698
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