NYC 9/11 Public Portal Document
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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)
Sample Type (circle one): c 9970. 96/9. P1. /9e
1. Potable . 3. Non-Potable Treated Bottle ws:39/ 663/ 224r
2. Non-Potable 4. Other___________ Chain of Custody? .yes no
Time/Date Collected; /0/03/0 / Comments
Collected By: C • Agency Code:. _ .Source ID:. .Type Descriptor:.
Collected From: Bill to.
Location’s/Individual’s Name__ MM _
Street___________________ Street_________
City/St/Zip_______________ City/St/Zip
Identification of Source • . Dt* Phone#: —Fax# ============= ="===========
Collection Point 33 oro Bcoys CA, CH, Bl? Check#: Amount$ ,* , .
BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES
Lab#:
(circle tests)
_______________ Lab#: ---- 70(74.4
(circle tests) • I • . f । ■
1. Heterotrophic Plate j. 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) 4
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)
8. Other:_________________ & Herbicides (515) 9. Petroleum Hydrocarbon Scan (310-13)
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) (13JGC/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
ki “
NAls
INORGANIC ANALYSES REQUESTED-Lab#:
(circle tests) . 2
1. Color 20. Acidity 39. Aluminum ’ 11 59. Potassium
2. T urbidity ? 21. Alkalinity, as CaCO3 40. Antimony 60. Selenium : 53
3. pH 22. Bromide 41. Arsenic 61. Silver | -d -
4. Conductivity 23. Bromate/Chlorate/Chlorite 42. Barium 62. Sodium 16/
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
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 4f
19. Other:____________ 38. UV254 57. Molybdenum 75. TCLP-BNA’s
58. Nickel
NYC-WTC_000027274
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