NYC 9/11 Public Portal Document
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Tme/Date Set:_____
Sample Type (circle one):
s
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
WESTCHESTER COUNTY LABORATORIES AND RESEARCH
•' *
2 Dana Road, Valhalla, New York 10595
(914) 593-5575
£70% "Scc 00+ 9977 4727 771o
NYS-ELAP No. 10108
Form A-70 (rev. 1/96)
1. Potable 3. Non-Potable Treated 04.79708 97" ________
2. Non-Potable 4. Other _________ _ Chain of Custody? yes .no
Time/Date Collected: IDf /2OO / 094 _ ____
Comments:
Collected By: ________Agency Code:....... ... .. _ .Source ID:. .Type Descriptor:.
Collected From: 5—5 Sl . Bill to:
Location’s/Individual’s Name_Woee=R{ Name/Company
Street__________ _ _____ _ Street_________ J
_ City/St/Zip
Identification of Source • . pt* Phonef_ Fax#:
Collection a050* 30941 CA,CH, Bl? Check#:. Amount$
BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES
Lab#:____________ __ _____
(circle tests)
Lab --
(circleteste) 6 100---
f l ~.
1. Heterotrophic Plate 1. Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260) <
Count (hemodialysis & all others) /a Volatile Halocarbons (524) 2. .Purgeable Aromatics (624/8260)
2. Coliform P/A (public supplies) P a Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624)
3. Coliform MPN (privwell, raw, stp) 4. Total Trihalomethane Potential (510) | 4. Phthalates (606/8060) d . 7
4. Fecal Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8080)
5. Microscopic 6. Pesticides (507) , 6. PCB’s (Arochlors) (608/8080) C
6.Macroscopic 0 Pesticides/PCB screen (508) 7. Herbicides (SM-18/6640; 8151) s. -
8. PCB as Decachlorobiphenyl (508A) 8. Other Pesticides (SM-18/6630) MEys
8. Other: 9. Herbicides (515) 9. Petroleum Hydrocarbon Scan (310-13.
Refrigerated? yes----- no
1 do) Pesticides (525)
11. Carbamate Pesticides (531)
- 10. Glycols in Water
11. Acid Extractable? (625/8270) .*
w.
12. Glyphosate (547) 12. Base Neutral Extractables (625/8:
Chionnated?: yes no 13. Diquat (549) (3.GC/MS Unknown Scan
ati Disinfection Byproducts (5511 14. Purgeable Halocarbons (DEF)
14. Chlorination
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
INORGANIC ANALYSES REQUESTED - Lab#:.
(circle tests)
1. Color 20. Acidity 39. Aluminum
Pidktol Yi ! '
59. Potassium ‘ < C
2. Turbidity 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. Soluble BOD (5 day) 25. Cyanide 44. Boron 64. Vanadium
7. 26. Fluoride 45. Cadmium 65. Zinc *_______
8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCO3 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 -
GFolids, Percent (%) 32. Oil and Grease 51. Copper 70, Disk Deliverables .
TSolids, 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
19. Other:____________ 38. UV254 57. Molybdenum 75. TCLP-BNA’s
58. Nickel____________
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NYC-WTC_000027642
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