NYC 9/11 Public Portal Document
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ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
II1
Time/Date Set:_____
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)
Cmple Type (circle one):
6 Potable 3. Non-Potable Treated Bom r. &0l8, 8700 8973, S'^^. 8781
4. Other_____________ Chain of Custody? yes no 9C7/7 7g s 4
2. Non-Potable
Time/Date Collected:. Comments: 7057. 797/ n3«/
Collected By: < •* Agency Code:. _ .Source ID:. .Type Descriptor.
Collected From: A/Le— Bill to:
Location’s/Individual’s Name. Name/Company__
Street___________
City/St/Zip______________
Identification of Source.
.
—w 299lo$
Street__________
City/St/Zip______
Phone#_ Fax #:
Collection Point, 20/5(/ Z ot 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 ( 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)
(19. 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)
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__
T- -****** . *
47 molals—
£
INORGANIC ANALYSI ES REQUESJEDNLabi:
(circle tests)
J 1. Color, •20. Acidity 9. Aluminum 59. Potassium
2. Turbidity 21 Alkalinity, as CaCOs 40. Antimony 60. Selenium
3. pH 22. Bromide 41. Arsenic 61. Silver
4. Conductivity : 28. 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 I
7. Soluble BOD (5 day) 26. Fluoride 45. Cadmium 65. Zinc___________
8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCO3 46. Calcium, 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 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
( Solids. Suspended 34. Phosphorus. Total as P 53. Lead 71. TCLP-Metals )
’ 46. 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. HV254 57. Molybdenum 75. TCLP-BNA’s
58. Nickel
whim al
NYC-WTC_000027111
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