NYC 9/11 Public Portal Document
UI
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
WESTCHESTER COUNTY LABORATORIES AND RESEARCH 4
2 Dana Road, Valhalla, New York 10595
Westchester County NYS-ELAP No. 10108
(914) 593-5575
(he/DateSet:_____ „ Form A-70 (rev. 1/96)
Sample Type (circle one): Qeul,GQE4,G-BC6Hl,k"leto,$07
pottle rs: 19645, PE44,(B9662,
C 1. Potable 3. Non-Potable Treated
_ * Chain of Custody? yes no F 80 " 4
2.Non-Potable 4. Other______ _____
Time/Date Collected: 6 5'1 2 4 ‘ _ Comments:
Xx Collected By: A NTM/ Agency Code: PWS #:_____ Source ID: Type Descriptor.
Collected From: Bill to:
Location’s/Individual’s Name ji et )
Name/Company.
Street, " I V ‘1 LLt -D+ V< Street •'
City/St/Zio A - NM 40 City/SVZip
Identification of Source____________ _ _________ • Phone#: Fax #:
Collection Point. De CJ C CA, CH, Bl?. Check#: Amounts
BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES
Lab#-:______________________ Lab #:____________________________
(circle tests) (circle tests) ,
1. Heterotrophic Plate 1. Trihalomethanes (524) i 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 ( Pesticides/PCB screen (508) 7T Herbicides (SM-18/6640; 8151)
( 7 ap; 8. PCB as Decachlorobiphenyl (508A) 4. Other Pesticides (SM-18/6630) 3
ber_____________ 9 Herbicides (515) 9. Petroleum Hydrocarbon Scan (310-13)*
(10.Pesticides (525) 10. Glycols in Water 4*
Refrigerated? .yes. .no 11. Carbamate Pesticides (531) 11. Acid Extractables (625/8270)
12. Glyphosate (547) 12. Base Neutral Extractables (625/8270)
Chionnated9: 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)
Tota’ Chlorine Res: .mg/L 17. Petroleum/Hydrocarbon Scan (310-13) 17. PCB’s (Arochlors) (DEF)
pH
*
{ « i r 7,
INORGANIC ANALYSES REQUESTED - Lab#: '■i
(circle tests;
1. Color 20. Acidity 39, Aluminum ■59. Potassium '
2. Turbidity 21. Alkalinity, as CaCOs (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 CaCO3 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
(Solids, Settleable 33. Phenol 52. Iron TCLP
Solids, Suspended 34. Phosphorus. Total as P 53. Lead 71. TCLP-Metals
16. Sclids, 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
(19Other 5 _____ 38. UV254 (57. Molybdenum 75. TCLP-BNA’s
58. Nickel
--in ------ saddneihadauaidati _st= _d
NYC-WTC_000027574
OCR can misread numbers and units. Confirm readings against the page image before using them.