NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
* Westchester
WWiv.com WESTCHESTER COUNTY LABORATORIES AND RESEARCH
Bott ‘ , 2 Dana Road, Valhalla, New York 10595
(914) 593-5575
NYS-ELAP No. 10108
Time/Date Set: Form A-70 (rev. 1/96)
Sample Type (circle one): 0084,0519,0391 ,3009,4624
1. Potable 3. Non Potable Treated Bottle #s:2409, 240,3 764, 3933 8966
2. Non Potable 4. Other ._________ Chain of Custody? yes no
Time/Date Collected: 200/ ■ A Comments:
Collected By: s " i / dp 11 Agency Code: _ Source ID: Type Descriptor:
Collected From: - , Bill to:
Location's/ndividual's Name. OQvtew) Nose+VOl Name/Company _
Street_____________ __________ ;____________________ Street________
Clty/St/Zip________ _ ________ ____________________ _ City/St/ZIp
Identification of Source __ ______ __ Phone#: Fax#:
Collection Point
4 .. t
CA,CH, Bl? Check#: Amounts.
4
BACTERIO‘LOGCALANALYSIS,
• — q.
, ORGANIC POTABLE ANALYSIS e ORGANIC NONPOTABLE/SOLID ANALYSIS
Lab#:__ _ ' Lab#:__________
(circle tests) ; " (circle tests) T
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 (priv well, raw, stp) 4. Total Trihalomethane Potential (510) 4. Phthalates (625/8270)
4. Fecal Coliform (ad samples) 5. Microextractables (504) 1 5. Organochlorine Pesticides (608/8081)
5. Microscopic 6. Pesticides (507) , 6. PCB’s (Arochlors) (608/8081)
6. Macroscopic * 7.Pesticides/PCB screen (508) 7. Methoprene (618)
ZPI 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151)
other___ 9. Herbicides (515) 9. Pesticides (SM18/6630) ;
Refrigerated? _ yes • no 10. Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13):
11. 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 (SM18/6630) 16. Purgeable Aromatics (DEF)
pH . 17. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB's (DEF)*
18. Other_______________________ 18. Other:_____________ __________
INORGANIC ANALYSIS REQUESTED - Lab#:
(circle tests)
1. Color
2. Turbidity
20. Acidity
21. Alkalinity, as CaCO3
230 -J7Aluminum
40. Antimony
59. Potassium
60. Selenium
t-
1227
.
■
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 CaCOs 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. Solids, Settleable 33. Phenol 52. Iron
TCLP
( Solids, Suspended 34. Phosphorus Total as P 53.Lead
71 TCLP-Metals
8. Solids, Total 35. Phosphorus, Ortho as P 54 Magnesium
36. Sulfates 55 Manganese
72.TCLP-Pesticides
17. Solids, Total Dissolved 73. TCLP-Herbicides
18. Solids, Total Volatile 37. Surfactants 56. Mercury
38. UV254 57 Molyodenum
74. TCLP-Volatiles
19. Other________________ 75.TCLP-BNAs
58. Nickel
T
A. . 4 —
NYC-WTC_000026699
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