NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
ester
ovcom WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
(914) 593-5575
NYS-ELAP No. 10108
Time/Date Set: Form A-70 (rev.1/96)
Ghpietype (circle one):
2933,8701 . cozo 4*15,1909,0022/1*
otable 3. Non Potable Treated Bottle #s: 3703,869 .294 8759, 8127 *sty
2. Non Potable 4. Other_____________________ Chain of Custody? yes no
Time/Date Collected: _ _________________ _ Comments:
Collected By:. tS4___ __ Agency Code: _ Source ID: Type Descriptor:
Collected From: Bill to:
Location’s/Individual’s Name Ousos Name/Company
Street________________ Street________
City/St/Zip_____________ City/St/Zip
Identification of Source' * ______ DeP L6# Phone#:______ Fax#:
Collection Point_ _ _____
*- ia; -■
*41^ .29 8/ CA.CH, Bl? Checkif: Amounts.
. 1-
.................................
BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS
Lab#:_____________ Lab#:______________________
(circletests) ar 4 (circle tests)
1. Heterotrophic Plate.' 1Trihalomethanes (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. Coliform MPN (priv well, raw, stp)
(3. Volatile Aromatics (524)
4. Total Trihalomethane Potential (510)
3. Acrolein & Acrylonitrile (624)
4. Phthalates (625/8270) e n
ri'
4. Fecal Coliform (aS samples) 5. Microextractables (504) 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 (616)
7API 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151)
_______________________ 9. Herbicides (515) 9. Pesticides (SM18/6630)
Refrigerated?— yes no 10.Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13):
Hr 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 Samivolatile 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___________________ _
T
INORGANIC ANALYSIS REQUESTED - Lab#:
(circle tests)
1. Color
2. Turbidity
20. Acidity
21. Alkalinity, as CaCO3
50 G 39. Aluminum
40. Antimony
) y. 59. Potassium
60. Selenium:
t2
co
6
-
< ■
3. pH 22. Bromide 41. Arsenic 61. Silver j
4. Conductivity 23. Bromate/Chlorate/Chiorite 42. Barium 62. Sodium ? .
5. Corrosivity (temp:__ °C) 24. Chloride 43. Beryllium 63. Thallium /
6. BOD (5 day) 25. Cyanide 44. Boron 64. Vanadium I A
7. Soluble BOD (5 day) 26. Fluoride 45. Cadmium 65. Zinc } V 1
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. Solids, Settleable 33. Phenol 52. Iron
TCLP
JSollids. 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
37. Surfactants 56. Mercury
73. TCLP-Herbicides
18. Solids, Total Volatile 74. TCLP-Volatiles
19. Other___________ 38. UV254 57 Molybdenum
58. Nickel
75.TCLP-BNAs
NYC-WTC_000026702
OCR can misread numbers and units. Confirm readings against the page image before using them.