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
NYS-ELAP No. 10108
Time/Date Set: Form A-70 (rev.1/96)
Spletypo (circle one):
8144,95*3ce 9 0033,7 y4 co6s
C1Potable 3. Non Potable Treated Bote *212 3958,76?% %906,8?%0
2. Non Potable 4. Other _____ Chain of Custody? yes no
Time/Date Collected: 9/25/200 / Comments:
Collected By. Y ♦ AGZ1 Agency Code: PWS#:_______ Source ID: .Type Descripton
Collected From: Bill to:
Location’s/Individual’s Name Oyookl Name/Company
Street .___________ Street________
City/St/Zip_____________ City/St/Zip_____ iai ~ 87 .
Identification of Source
24450
D LAP*
.290% 2.
Phone#:______ Fax#: ate
■ 254*5755* .
Collection Point
CA,CH, Bl? Check#: Amoums—TZ
BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLIP ANALYSIS
Lab#: Lab#:______________________ ' de
(circle tests) (circle tests) : . : -W
1. Heterotrophic Plate 1.Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260) a l
Count (hemodialysis & all others) (24 Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260) L.
2. Coliform P/A (public supplies) (3. Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624) a"
3. Coliform MPN (priv well, raw, stp) 4. Total Trihalomethane Potential (510) 4. Phthalates (625/8270) Y®
4. Fecal Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8081) a
5. Microscopic . 6. Pesticides (507) 6. PCB’s (Arochlors) (608/8081) . sr
6. Macroscopic (7.Pesticides/PCB screen (508) 7. Methoprene (616) 9
Gr— 8. PCB as Decachlorobiphenyl (508A)
9. Herbicides (515)
(10 Pesticides (525)
8. Herbicides (EPA1978/8151)
9. Pesticides (SM18/6630)
ellt.»
10. Petroleum Hydrocarbon Scan (310-13) '
Refrigerated? yes no 11. Glycols ..
11. Carbamate Pesticides (531)
Chlorinated:? i 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
mg/L 15. Haloacetic Acids (552) -
15. Purgeable Halocarbons ■(DEF) t
Total Chlorine Res:
16. Pesticides (SM18/6630) 16. Purgeable Aromatics (DEF) 57s
PH 17. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB's (DEF) C
18. Other_______________________ 18. Other:__________________ &
uuTCJ ' Jim
INORGANIC ANALYSIS REQUESTED - Lab#:
(circle tests)
1. Color
2. Turbidity
20. Acidity
21. Alkalinity, as CaCOs
39. Aluminum
40. Antimony
3 59. Potassium '
60. Selenium :
"to 9
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
44. Boron
63. Thallium | • x
64. Vanadium '
6. BOD (5 day) 25. Cyanide
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. Cobait 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
Solids, Total 35. Phosphorus, Ortho as P 54 Magnesium
72.TCLP-Pesticides
17. Solids, Total Dissolved 36. Sulfates 55 Manganese
73.TCLP-Herbicldes
18. Solids, Total Volatile 37. Surfactants 56. Mercury
38. UV254 57 Molybdenum 74. TCLP-Volatiles
19. Other:________________ 75.TCLP-BNAs
58. Nickel
- -— -st......
NYC-WTC_000026700
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