NYC 9/11 Public Portal Document
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ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
WESTCHESTER COUNTY I ABORATORIS AND REST ARCH orPae
2 Dana Road, Valhalla, New York 10595
Uestchester County
14593-5575 ,NYS-ELAP No. 10108
me/DateSet:_____________ :___ Form A-70 (rev. 1/96)
Cemple Type (circle one): orBAEo0C920 ZpreM=96Lko
Bottle #‘s:_ __2ifc
P. .1 5027 .
( Potable 3. Non-Potable Treated
2. Non-Potable 4. Other_ Chain of Custody? yes no L ) ( , LEEIl"ULD
Time/Date Collected: K1t_ jo-c1-0k. Comments: - - ----------------------------------------
Collected BytCT _Agency Code:___ PWS #:............. . Source ID: Type Descriptor:
Collected From: Bill to
Location’s/Individual’s Name - Name/Company_____
Street____ : 5...... .... .................. .. Street
City/SvZp_. 4 -A__ L City/St/Zip........ ...........
Identification of Source_ ________________ Phone#: ............. = .......... Fax #:
Collection Point___ _________ ___ CA, CH, Bl?_______ Check#: Amounts
BACH OA—SKAl ANAlYS-LS ONGAMPriA/t ANAY: • OHANC NONTOIABL F /S1.0 ANALYE 5
Lab#:.__ _____________________ Lab#
(circle tests) (circle tests) LOGAeEEs
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 f’/A (public supplies) 132 Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624)
3. Conform 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 [7.1 Pesticides/PCB screen (508) ' 7. Herbicides (SM-18/6640; 8151)
7.APW 8. PCB as Decachlorobiphenyl (508A) 8 Other Pesticides (SM-18/6630)
-Others 9. Herbicides (515)
(10, Pesticides (525)
9. Petroleum Hydrocarbon Scan (310-13)
10. Glycols in Water
Memoerated? yes no IT. 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; . ....... ; ■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)
( y
**, .AMI' A.02"/SHGULSTFD-f : ■ /
(circle tests)
. Color d 20.Acldily 39. Aluminum 4r* _
3as5 59. Potassium
12.5 Turbidity 0 :24. Alkalinity, as CaCOs
(40. Antimony / * > 60. Selenium
3 PH
4. Conductivity
a 23. Bromate/Ch lorate/Chiorite 42.Banum
22. Bromide 41. Arsenic 61. Silver
62, Sodium
5. Corrosivity (temp:........ _ "C) 24. Chloride £3. Beryllium 63-Thallium
iemeemioeu
C. BOD (5 day) .25.-Cyanide 44. Boron (§4,-Vanadium
7. Soluble BOD (5 day) 26. Fluoride 45. Cadmium 65. _________
8 Carbonaceous BOD (5 day) 27. Hardness, Total as CaCO2 46. Caicium, as CaCO3 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 , 43. 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, Totlf Kjeldahl as N (50./Cobalt 6.* Pethio-d-si ‘ .
13. Solids. Percent (%) 32. Oil and Grease 51. Copper 70 1 k ! olpal lo ■
- 33, Phenol 53.Leads
4. Solids, Settleable 52.Iron 71.TCLP-Metals
TCLP
□lids. Suspended
olids. Total
36. Sul f ates e' '
— .54.
55. Magnesium dvr
34. Phosphorus, T otal as P
Manganese
35. Phosphorus, Ortho as P A 1o I’ ! der
/ iQPHerbijet,
Surfactants. 157
(19 Other en1ate 37.38.UV254mzdanraas
17. Solids, Total Dissolved
518. Solids. Total Volatile 56.Mercurynhgsednes
Molybdenum A /4 iC f VoU.I-r.
7, IGPBNA
w58. Nickel
aaso
NYC-WTC_000027069
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