NYC 9/11 Public Portal Document
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ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM J i
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gime/DateSet:_____
WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
(914) 593-5575
>$‘7-7517 *r/c ‘ *5-275* 5 -A')
NYS-ELAP No. 10108
Form A-70 (rev. 1/96) -
Cample Type (circle one):
Bottle wao"**-irey *3 9, - 24
3 Potable
2. Non-Potable
3. Non-Potable Treated
4. Other_____ Chain of Custody?_____ yes no
Time/Date Collected: /Lyi 260 ‘ Comments:_____________
Collected By: 7-o4 - 24 • • Agency Code:
PWS #:_____ Source ID: Type Descriptor:.
Collected From: Bill to:
Location’s/Individual’s Name. Aillv-ois Name/Company.
Street__________________ Street________
City/St/Zip_______________ Citv/St/Zio
Identification of Source____ Phone#: .Fax #:
Collection Point. BASS CA, CH, Bl? Check#: Amounts,
BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES
Lab#:______________________ Lab _____________________________
. (circle tests) (circle tests)
1. Heterotrophic Plate 1. Trihaiomethanes (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 8. PCB as Decachlorobiphenyl (508A) 8. Other Pesticides (SM-18/6630)
, ,8. Other:___________________ 9? Herbicides (515) 9. Petroleum Hydrocarbon Scan (310-13)
(d Pesticides (525) 10. Glycols in Water
“Refrigerated?_____yes no 11. Carbamate Pesticides (531) 11. Acid Extractables (625/8270) > 5,
‘
Chlorinated?:_____yes
/
no
12. Glyphosate (547)
13. Diquat (549)
12. Base Neutral Extractables (625/8270)
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)
pH __ _________ _ ______ _ ______ _ _____
INORGANIC ANALYSES nEGUESTEDSCsb#
(circle tests) f
20. Acidity
-424047 S 39. Aluminum 4
1. Color 59. Potassium
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 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
14. Solids, Settleable 33. Phenol 52. Iron TCLP
C. Solids. Suspended 34. Phosphorus. Total as P 53. Lead 71. TCLP-Metals ?
"6. 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_000027108
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