NYC 9/11 Public Portal Document
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ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
Ill
Ulestchester County 200 -
gne/DateSet:___ _________________
WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
(914) 593-5575 NYS-ELAP No. 10108
Form A-70 (rev. 1/96)
“Wimple Type (circle one): *6 7
1. Potable 3. Non-Potable Treated Bottle #‘s: i'iy'
2. Non-Potable 4. Other ____________________ Chain of Custody? .yes no
Time/Date Collected: __________ _ , Comments:
Collected By: H ■ Pol_______ Agency Code:
PWS#:_________ Source ID: Type Descriptor:
Collected From: Bill to:
Location’s/Individual’s Name. C,Z Name/Company
Street 1 Street__________
City/StZip Civ/SVZio
identification of Source. _AA8 Phone#: Fax#:
Collection Point. &RSD 24146 CA, CH, BI? Check#: Amounts.
BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES
Lab#:_____________ -____ Lab #:_________________________
(circle tests) (circle tests)
1. Heterotrophic Plate 1. Trihalomethanes (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/ 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 i 8. PCB as Decachlorobiphenyl (508A) 8. Other Pesticides (SM-18/6630)
_ 9. Herbicides (515) 9. Petroleum Hydrocarbon Scan (310-13)
(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)
pH
INORGANIC ANALYSES REQUESTED - Lab#:
(circle tests)
220 0 S. Potassium
1. Color 20. Acidity 39. Aluminum
2. Turbidity 21. Alkalinity, as CaCO3 40. Antimony 60. Selenium
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 CaCOa 46. Calcium, as CaCO, CLP
9. Chemical Oxygen Demand 28. Nitrogen, Ammonia as N 47. Calcium, Ca*2 66. Metais/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
TCLP
0
Solids, Settleable 33. Phenol 52. Iron
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-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_000026947
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