NYC 9/11 Public Portal Document
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ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
WESTCHESTER COUNTY LABORATORIES AND RESEARCH 15
2 Dana Road, Valhalla, New York 10595 ’
(914) 593-5575 NYS-ELAP No. 10108
Time/Date Set:_________ Form A-70 (rev. 1/96)
Sample Type (circle one): ?&• 7620 / 7.” : 2 ■
1 / Potable 3. Non-Potable Treated Bottle wab14 7327 .27 // *6/0 6/)
2. Non-Potable 4. Other_____ Chain of Custody?_____ yes .no
Time/Date Collected: 1/2/2co ‘ _____ 4 Comments:_____________
Collected By:l GAck ' 27 .Agency Code: PWS#:_______ .Source ID:_______ Type Descriptor:.
Collected From: Bill to:
Location’s/Individual’s Name. ( h . Name/Company.
Street__________________ _ Street________
City/St/Zip_______________ _
identification of Source pt/* Phone#:. Fax«:
Collection Point. 100 •001+ CA.CH, Bl?^ Check#: Amounts
BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES
Labe:___________________
(circle tests)
1. Heterotrophic Plate
Lab#:
(circle tests) 42419
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) .2. 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) W
T. 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)
Chiorated?: 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 SB
INORGANIC ANALYSES REQUESTED Lab#:.
(circle tests) 53
1. Color 20. Acidity 39. Aluminum 59. Potassium •
2. T urbidity 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 CaCO3 46. Calcium, as CaCOa 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, Nitrile 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 ISLE
15. Solids. Suspended 34. Phosphorus. Total as P 53. Lead 71. TCLP-Metals
16. 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_000027272
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