NYC 9/11 Public Portal Document
re
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
seer WESTCHESTER COUNTY LABORATORIES AND RESEARCH
vcom
2 Dana Road, Valhalla, New York 10595
(914) 593-5575 •mm
@eD ate Set: C.
»— .
2.4, , . fz T' /;
NYS-ELAP No. 10108
Form A-70 (rev.1/96)
Sample Type (circle one): g,90i1/20022----------
Bottle22592 .893 ,7___________
1. Potable 3. Non Potable Treated
2. Non Potable 4. Other ________ ___________ Chain of Custody? yes no
Time/Date Collected: / ' 7 /C / $1 P
Comments:
Collected By: / / 67 (Ao //A Agency Code: PWS#:_______ source ID: .Type Descriptor
Collected From: Bill to:
Location’s/dividual’s Name ■ ' C "e • Name/Company
Street_________________________________ _________ Street________
City/St/ZIp________________________________________ _
Identification of Source' + ________________________ Phone# _ _____ Fax#
Collection Point //U8 --------------------------------- CA.CH, Bl? . Check#: Amounts.
454
BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS — ORGANIC NONPOTABLE/SOLID ANALYSIS
Lab#:____________________
(circle tests)
1. Heterotrophic Plate
C4VT
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) (3. Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624)
3. Coliform MPN (priv well, raw, stp) 4. Total Trihalomethane Potential (510) 4. Phthalates (625/8270) pt
4. Fecal Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8081) 55
5. Microscopic 6. Pesticides (507) 6. PCB's (Arochlors) (608/8081) .
Scroscopig ( Pesticides/PCB screen (508) 7. Methoprene (616) 4 V,
8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151) —
8. Other:__________________ 9. Herbicides (515) 9. Pesticides (SM18/6630) -
10) Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13) .
Refrigerated? yes no
11. Carbamate Pesticides (531) 11. Glycols
Chlorinated:? yes no 12. Glyphosate (547) 12. Add Extractables (625/8270)
13. Diquat (549) 13. Base Neutral Extractables (625/8270)
Free Chlorine Res:. mg/L 14. Chlorination Disinfection Byproducts (551) 14.GC/MS Semivolatile Unknown Scan
Total Chlorine Res: mg/L 15. Haloacetic Acids (552) 157 Purgeable Halocarbons (DEF)
16. Pesticides (SM18/6630) 16. Purgeable Aromatics (DEF)
pH 17. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB’s (DEF)
18. Other_______________________ 18. Other___________ _____________
INORGANIC ANALYSIS REQUESTED - Lab#:
(circle tests)
1. Color 20. Acidity 39. Aluminum
al 59. Potassium
2. Turbidity 21. Alkalinity, as CaCOs 40. Antimony 60. Selenium
3. pH 22. Bromide 41. Arsenic 61. Silver •
r
4. Conductivity 23. Bromate/Chlorate/Chlorite 42. Barium 62. Sodium ’
I
5. Corrosivity (temp:. °C)
24. Chloride 43. Beryllium
44. Boron
63. Thallium'
6. BOD (5 day) 25. Cyanide 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-violatiles
12/ Total Organic Halides 31. Nitrogen, Total Kjeldahl as N SO.Cobalt 69. Pesticldes/PCB’s
13.Solids, Percent (%) 32. Oil an Grease 51. Copper 70. Disk Deliverables
Colids, Settleable 33. Phenol 52. Iron
TCLP
15. Solids, Suspended 34. Phosphorus Total as P 53.Lead
54 Magnesium 71 TCLP-Metals
16. Solids, Total 35. Phosphorus, Ortho as P
55 Manganese 72.TCLP-Pesticides
17. Solids, Total Dissolved 36. Sulfates
56. Mercury 73. TCLP-Herbicldes
18. Solids, Total Volatile 37. Surfactants
19. Other________________ 38. UV254 57 Molybdenum 74. TCLP-Volatiles
75.TCLP-BNA’S
58. Nickel
--- Bnssan
NYC-WTC_000027647
OCR can misread numbers and units. Confirm readings against the page image before using them.