NYC 9/11 Public Portal Document
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ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
(914) 593-5575 NYS-ELAPNo. 10108
Date Set____ Form A-70 (rev. 1/96)
Sailiple Type (circle one): 843 oQ4>,13297370,262/
1) Potable 3. Non-Potable Treated Bottle #s0/03,8829, 883 2, 880% 339 2815
2. Non-Potable 4. Other—_________ —_____________ Chain of Custody? yes no
Time/Date Collected:9.23/200 / 7~______
Comments:___
Collected By: Vi Agency Code: - a _ .Source ID:. Type Descriptor:.
Collected Fromlreel7 Vcjlev/os 6776 Bill to:
Location’s/lndividuars NameNLQOvew) Cse+Do/y. Name/Company.
Street_________s________ Street________
City/St/Zip______________ City/SVZip_
Identification of Source Phone#: Fax #: I
Collection Point 043 . CA, CH, Bl? Check#: Amounts.
BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES
Lab#:____________________
(circle tests)
1. Heterotrophic Plate
LB.t.. 33835 1
1. Trihalomethanes (524) , de 1. “Purgeable Halocarbons (624/8260) . 42
Count (hemodialysis & all others) 2. Volatile Halocarbons (524) i ' . 2. Purgeable Aromatics (624/8260) * 14
2. Coliform P/A (public supplies) 3. Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624) t
3. Coliform MPN (priv well, raw, stp) 4. Total Trihalomethane Potential (510) . 4. Phthalates (606/8060)
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4. Fecal Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8080)
5. Microscopic Pesticides(507) 6. PCB’s (Arochlors)(608/8080) 7
6. Macroscopic Pesticides/PCB screen (508) 7. Herbicides (SM-18/6640; 8151)
7. API 8. PCB as Decachlorobipheny! (508A) - / 8. Other Pesticides (SM-18/6630)
_ 9. Herbicides (515) . 9. Petroleum Hydrocarbon Scan (310-13) /
C 10. Pesticides (525) 10. Glycols in Water
Refrigerated? yes no 11. Carbamate Pesticides (531) 11. Acid Extractables (625/8270)
12. Glyphosate (547) 12. Base Neutral Extractables (625/8270)
Chlorinated?: yes_____ no 13. 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)
16. Other Pesticides (SM-18/6630) 16. Pesticides (DEF)
Total Chlorine Res: mg/L 17. Petroleum/Hydrocarbon Scan (310-13) 17. PCB’s (Arochlors) (DEF)
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pH w 1
INORGANIC ANALYSES REQUESTED - Lab#:.
' (eircle tests)
1. Color 20. Acidity 39. Aluminum 59. Potassium
2. Turbidity 21. Alkalinity, as CaCOs 40. Antimony 60. Selenium y IV
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-volatiles
12. Total Organic Halides 31. Nitrogen, Total Kjeldahl as N 50. Cobalt 69. Pesticides/PCB’s
13. Solids, Percent (%) 32. Oil and Grease 51. Copper 70. Disk Deliverables
at Solids, Settleable 33. Phenol 52. Iron ISLE
Colids, Suspended 34. Phosphorus. Total as P 53. Lead 71. TCLP-Metals
16. 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 74. TCLP-Volatiles
19. Other:_____________ 38. UV254 57. Molybdenum 75. TCLP-BNA’s
58. Nickel______________
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NYC-WTC_000026865
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