NYC 9/11 Public Portal Document
JU
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
(914) 593-5575 NYS-ELAP No. 10108
Time/Date Set:___ _ ___ ___________________ Form A-70 (rev. 1/96)
CpleType (circle one):
1) Potable - 3. Non-Potable Treated 355 8ws 3533 $233i O1C3 290
Bottle rs:_____________________
2. Non-Potable 4, Other______ ______________________ Chain of Custody?_____ yes no
Time/Date Collected: (0/ 2/cn ______ 1 • 46__ Ar
Comments:_____________
Collected ByaRRk/0A//AAgncy Code: PWS#:_______ .Source ID:_______ Type Descriptor:.
Collected From:
Bill to:
Location’s/Individual's Name __ ________________________
Name/Company.
Street _____________________________ Street________
_______________________________________________ City/St/Zip_____
Identification of Source____________________________ Phone#:. Fax#:.
Collection Point S2 S Co CA, CH, Bi? Check#: Amounts,
BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES
Lab#:______________________
(circle tests)
Lab#:-------47 C)J 7()
(circle tests) •* C .
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) s:
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) 1.
7. API 8. PCB as Decachlorobiphenyl (508A) 8. Other Pesticides (SM-18/6630)
8Qther 9. Herbicides (515) 9. Petroleum Hydrocarbon Scan (310-13) '
(10, Pesticides (525) 10. Glycols in Water
Herrigerated? 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 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
‘ 3.
4
INORGANIC ANALYSES REQUESTED ALab#:
(circle tests)
1. ’ Color
:’
20. Acidity 39. Aluminum
MW 59. Potassium
£7
2. Turbidity 21. Alkalinity, as CaCOs 40. Antimony 60. Selenium
3. pH 22. Bromide 41. Arsenic 61. Silver
4. Conductivity 23. Bromate/Chlorate/Chiorite 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. Floride 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
Eolids, Suspended 34. Phosphorus. Total as P 53. Lead 71. TCLP-Metals
TSclids, 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
szB
NYC-WTC_000027196
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