NYC 9/11 Public Portal Document
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ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
WESTCHESTER COUNTY LABORATORIES AND RESEARCH
IUestchester County
2 Dana Road, Valhalla, New York 10595
TTEE(914)593-5575OT
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NYS-ELAP No. 10108
be/Date Set: Form A-70 (rev. 1/96)
mple Type (circle one): 67 S /2
1. Potable 3. Non-Potable Treated
) r . " • / ,
Bottle #‘s: _ 1* ■■ 99 /$
2. Non-Potable 4. Other Chain of Custody7 . ..... ....yes... no C P 23 7 - 44 1
( S ‘ 4/ 4 J
Time/Date Collected://. . J.---- Comments:
Collected ByL Agency Code PWS #... .. Souman ID:• Type Descriptor:
Collected From: . Bill to:
Location’s/Individual's Name --- ‘ Name/Company
Street I £____ /. 14 y_ 5 Street_________
J / / (.1 1 7 .g
III City/StZip City/StZip.
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in Identification of Source_____
S.. a... .
Phone#: .
I CA. CH. BP
Fax #
Collection Point . _ -_______ ____ _ ...... Check#:.......... .Amounts....
BACTERIOLOGICAL ANALYSES' ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES
Lab# Lab #:___ _ ___ _ ______ ______ ....
(circle tests)
T HeYSrotronhic /date 1. Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260)
Count themodlazysis & all others) ( 2.7 Volatile Halocarbons (524)
2. Coliform P/A (public supplies) ( 3) Volatile Aromatics (524)
i 3. Coliform MPN (priv well, raw, stp) "4. Total Trihalomethane Potential (510) 4. Phthalates (606/8060)
4 Fee al Coliform (all samples) 5. Microextractables (504) _5. Organochlorine Pesticides (608/8080)
5. Microscopic 6. Pesticides (507) ' 6.. PCB’s (Arochlors) (608/8080)
6. Macroscopic 7. Pesticides/PCB screen (508) 7 ’ Herbicides (SM-18/6640; 8151)
API 8. PCB as Decachlorobiphenyl (508A) 8. Other Pesticides (SM-18/6630)
Or--. -... -.. -
Retngerated? ...... ...yes__ ___ no
9. Herbicides (515)
C 10? Pesticides (525)
11. Carbamate Pesticides (531)
9. Petroleum Hydrocarbon Scan (310-13)
10. Glycols in Water
11. Acid Extractables (625/8270)
12. Glyphosate (547) 12. Base Neutral Extractables (625/8270)
Chignnated?: yes .. .no 1 3. Diquat (549) 13. GC/MS Unknown Scan
14. Chlorination, Disinfection Byproducts (551) 14. Purgeable Halocarbons (DEF)
Free Chlorine Res: mg/L 15. Haloacetic Acids (552) 15 Purgeable Aromatics (DEF) i
16. Other Pesticides (SM-1 8/6630) 16. Pesticides (DEF) i
Tola Chlorine Res: ..._mg/L 17. Petroleum/Hlydrocarbon Scan (310-13) 17. PCB's (Arochlors) (DEF) i
pH....
—B—' -87.-.-
INORGANIC ANALYSES REQUESTED - Lab#:... _.. _ r. -. L. .. ..
(circle tests)
i. 20. Acidity- /39. Aluminum 59. Potassium
Tubidity 21. Alkalinity, as CaCOa j 40. Antimony / 60. Selenium ■
■|
pHMaeem 22. Bromide ■ 41.; Arsenic ( 61. Silver
i 62. Sodium U
4. Conductivity 23. Bromate/Chlorate/Chlorite . 42. Barium
5. Corrosiv ity (temp:...... _.. °C) 24. Chloride | 43. Beryllium I 63. Thallium
ROD (5 day) 25. Cyanide 1-44. Boron < 64 Vanadium
71 Soluble BOD (5 day) 26. Fluoride i 45. Cadmium -65. Zinc
6 Carbonaceous BOD (5 day) 27. Hardness. Total as CaCO 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-volatiles
12 Total Organic Haldes 31. Nitrogen, Total Kjeldahl as N .<"'50,. Cobalt 69. Pesticides/PCB’s
13. Solids, Percent (%) 32. Oil and Grease j 51 Copper 70. Disk Deliverables
L Solids, Settleable 33. Phenol 52. Iron TCLP
5. Solds, Suspended 34. Phosphorus, Total as P 58. Lead 71. TCLP-Metals
16 Solids, Total 35. Phosphorus. Ortho as P 54. Magnesium 72. TCLP-Pesticides
17. Solids, Total Dissolved 36. Sulfates 1 55. Manganese 73' TCLP-Herbicides
18 Solids. Total Volatile 37 Surfactants { 56. Mercury 74. TCLP-Volatiles
19 Other *_ ' : 38.UV254 | 57. Molybdenum
i 58. Nickel
75. TCLP-BNA's
NYC-WTC_000026756
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