NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM /
(3)
100
Ulestchester County
ATime/DateSet:_____
WESTCHESTER COUNTY LABORATORIES AND RESEARCH
. c
2 Dana Road, Valhalla, New York 10595
(914) 593-5575
•1
, NYS-ELAP No. 10108
Form A-70 (rev. 1/96)
mple Type (circle one): —co/fj. 9569 8926,8*55—n
(1 Potable 3. Non-Potable Treated Bomlo «8$,% 271*755*0* 2*82*6
2. Non-Potable 4. Other_____________ Chain of Custody? yes no
Time/Date Collected:.
Collected By: C
/0/0//2001
Tsui Agency Code;
084/ Comments:
_ .Source ID:.
___ 2
.Type Descriptor.______
Collected From: Bill to:
Location’s/Individual’s Name_____ 9Mn _
Street_______________________ Street__________
_ _
Identification of Source D&P * Phone#:_ ____ Fax#:.
Collection Point 30250 29178 CA, CH, Bl?. Check#: Amounts.
BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES
Lab#:__________________ Lab#:___________________
(circle tests) (circle teste)
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 8. PCB as Decachlorobiphenyl (508A) 8. Other Pesticides (SM-18/6630)
-8 Other 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/Lr, 17. Petroleum/Hydrocarbon Scan (310-13) 17. PCB’s (Arochlors) (DEF)
pH ?
—
s neQuesfeosLaor- —U2 -
INORGANIC ANALYSI
(circle tests)
1. Color
2. T urbidity
3. pH
%o.Apidy 24 Glinum
21'. Alkalinity, as CaCOs
" 22. Bromide
40. Antimony
41. Arsenic
mads
V
59. Potassium
60. Selenium
61. Silver
4. Conductivity 23. Bromate/Chlorate/Chiorite 42. Barium 62. Sodium
5. Corrosivity (temp: O 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
8. 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
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NYC-WTC_000027112
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