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-ELAP No. 10108
Time Date Set: ____ Form A-70 (rev. 1/96)
SleType (circle one):
720 3 ,0347,3044 1179.72S8
(Potable 3. Non-Potable Treated Bottle «-S: O/V 3,F2 t 5 . 1 ; 935 2, 584
2. Non-Potable 4. Other Ql rroel Chain of Custody? yes .no
Time/Date Collected:. 22/20/07 2 Comments:
Coll OUUn Agency Code:_ PWS#:_________ Source ID: Type Descriptor:.
Collected From: Bill to:
Location’s/ndividual’s Name Bibx) _
Street_________ s____________________ Street__________
City/St/Zip___________________________ City/St/Zip
Identification of Source ~ -____________ DP(A6* Phone#_ .Fax #:.
Collection Point _50 — 05 CA, CH, Bl? Check#:. Amounts.
BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES
Lab#:__________________ Lab#: 0 2, ‘ : ps ■ •
(circle tests) (circle tests) ./ C 7 urgh ■
sek.
1. Heterotrophic.Plate Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260) , :
Count (hemodialysis & all others) “ olatile Halocarbons (524) 2. Purgeable Aromatics (624/8260) P**
2. Coliform P/A (public supplies) __ Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624)
3. Coliform MPN (priv well, raw, stp) 4. Total Trihalomethane Potential (510) 4. Phthalates (606/8060)'
4. Fecal 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)
7. API 8. PCB as Decachlorobiphenyl (508A) 8. Other Pesticides (SM-18/6630)
8.Gther 9. Herbicides (515) 9. Petroleum Hydrocarbon Scan (310-13) 5
< 10. Pesticides (525) 10. Glycols in Water
Remgerated? yes no 11. Carbamate Pesticides (531) 11. Acid Extractables (625/8270)
12. Glyphosate (547) 12. Base Neutral Extractables (625/8270)
Chionnated?: .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)
pH.
-====%
INORGANIC ANALYSES REQUESTED - Lab#:.
(cirele tests)
---------------- ----------------
C
1. Color 20. Acidity 39. Aluminum 59. Potassium =
2. Turbidity 21. Alkalinity, as CaCO3 40. Antimony 60. Selenium
3. pH
4. Conductivity
22. Bromide
23. Bromate/Chlorate/Chlorite
41. Arsenic
42. Barium
61. Silver
62. Sodium h/1
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 CaCO3 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 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
14, Solids, Settleable 33. Phenol 52. Iron TCLP
1Gplids, Suspended 34. Phosphorus. Total as P 53. Lead 71. TCLP-Metals
18Eclids, 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
NYC-WTC_000026871
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