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 *57
(914)593-5575 _ NYS-ELAP No. 10108
gime/Date Set: _____ _________ C=0/S Form A-70 (rev. 1/96)
' Wamplu lypo (i in le one): G - 2573 , X/63,74
1 Potable 3. Non-Potable Treated Bomo s.PosssO
2. Non-Potable 4. Other _________ Chain of Custody? ’ ves' " no f f
/ , /) .{A r A
Time/Date Collected:. Comments:___
Collected By: / • A/HAgency Code: _ .Source ID:. Type Descriptor..
Collected From: Bill to:
Location's/Individual's Name..X Name/Company.
Street______________________ Street________
City/St/Zip__________________ City/St/Zip_____
Identification of Source________ Phone#:,. Fax#:.
Collection Point, AX 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. Coliform P/A (public supplies)
3. Coliform MPN (priv well, raw, stp)
© Volatile Halocarbons (524)
Volatile Aromatics (524)
4. Total Trihalomethane Potential (510)
2. Purgeable Aromatics (624/8260)
3. Acrolein & Acrylonitrile (624)
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)
B Other 9. Herbicides (515) 9. Petroleum Hydrocarbon Scan (310-13)
AS Pesticides (525) 10. Glycols in Water
Refrigerated? yes no T1. 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 Chionne 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)
8 _ _____
______
pH.
“ rm
INORGANIC ANALYSES REQUESTED fLabl:______L
(circle tests)
1. Color
’ t
20. Acidity
<
*Y
—7—
39. Aluminum
(Nota (s. p0ta8SiUmj
2. Turbidity 21 Alkalinity, as CaCOa 40. Antimony 60. Selenium «
3- pH
4. Conductivity
20 Bromide *
23 Bi jimate/Chlorate/Chlorite
41. Arsenic 61. Silver |
..
42. Barium 62. Sodium
5. Corrosivity (temp:______°C)
°C) 24 Chloride 43. Beryllium 63. Thallium ‘
6. BOD (5 day) 28.Gvanide 44. Boron 64. Vanadium Y
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
4814 Solids. Settleable 33. Phenol 52. Iron TCLP
( Solids, Suspended 34. Phosphorus. Total as P 53. Lead 71. TCLP-Metals 1
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
5
NYC-WTC_000027043
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