NYC 9/11 Public Portal Document
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Time/Date Set:_________
Sample Type (circle one):
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
(914) 593-5575
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NYS-ELAP No. 10W
Form A-70 (rev. 1/96)
11 .
1. Potable . 3. .Non-Potable Treated Bottle #s:GI e ,, *Sh-01
2. Non-Potable 4. Other_____________ Chain of Custody? yes .no
Time/Date Collected:. 21 0S8 Comments:
Collected By: Varss .Agency Code:. PWS#:__________ .Source ID:. .Type Descriptor:.
Collected From: Bill to:
Location’s/Individual’s Name.
84 e-t*pp ", Name/Company___
Street__________ _______ Street___________
City/St/Zip_______________ dky/SVZip
Identification of Source • . 0 P 4 Phone#:, Fax #
Collection Point 30020 CA, CH, Bl? Check#: Amounts.
BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES. A ORGANIC NONPOTABLE/SOLID ANALYSES
Lab#:_________ — Lab,*:--------- — L 0 I
(circle tests) (circle tests) 'A i
V 1. Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260)
1. Heterotrophic Plate
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 s"
Refrigerated? ves_____ 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 ana
--------------------------- * 4 :-----
INORGANIC ANALYSES REQUESTED? Lab#:
(circle tests) ! 4
1. Color 20. Acidity 39. Aluminum 59. Potassium
2. Turbidity 21. AJkalinity, as CaCO3 40. Antimony 60. Selenium .)
3. pH 22. Bromide 41. Arsenic 61. Silver C2 w
• -es
4. Conductivity 23. Bromate/Chiorate/Chlorite 42. Barium 62. Sodium
5. Corrosivity (temp: .°C) .24. Chloride 43. Beryllium 63. Thallium
6. BOD (5 day)
7. Soluble BOD (5 day)
25. Cyanide
26. Fluoride
44. Boron
45. Cadmium
64. Vanadium
65. Zinc iI
8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOa 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, 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-Volatlles
19. Other:_________________ 38. UV254 57. Molybdenum 75. TCLP-BNA’s
58. Nickel
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NYC-WTC_000027276
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