NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
Ster WESTCHESTER COUNTY LABORATORIES AND RESEARCH
com
2 Dana Road, Valhalla, New York 10595
(914) 593-5575
@e/Date Set: NYS-ELAP No. 10108
0346, Y- / 64592479rev.1/96)
Sample Type (circle one):
b. Potable 3. Non Potable Treated
s 42016,001"
Bottlers.- -‘‘Ui 1________________________
2. Non Potable 4. Other___________ Chain of Custody? yes no
Time/Date Collected: . • li :- * Comments:
Collected By: f Agency Code: _ Source ID: .Type Descriptor
Collected From: Bill to:
Location’s/ndividual’s Name. lruavll/ic” Name/Company _
Street________________ Street________
City/St/Zip_____________ City/St/Zip
Identification of Source * Phono#:______ Fax#
Collection Point t-A .
CA.CH, Bl? Check#: _ Amounts.
BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS / ORGANIC NONPOTABLE/SOLID ANALYSIS
Lab#:____________________ Lab#:------ -- / J (/C
(circle tests) (circle tests) - / (f |
1. Heterotrophic Plate 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) P*)
3. Coliform MPN (priv well, raw, stp) > ...
4. Total Trihalomethane Potential (510) 4. Phthalates (625/8270) .2
4. Fecal Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8081)
5. Microscopic 6. Pesticides (507) 6. PCB’s (Arochlors) (608/8081)
@croscopic ( Pesticides/PCB screen (508) 7. Methoprene (616)
Wl 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151)' . 3
8. Other__________________ 9. Herbicides (515) 9. Pesticides (SM18/6630)
(0, Pesticides (525)
Refrigerated? yes no
11. Carbamate Pesticides (531)
10. Petroleum Hydrocarbon Scan (310-13)
11. Glycols
Chlorinated:? yes no 12. Glyphosate (547) 12. Acid Extractables (625/8270)
13. Diquat (549) 13Base Neutral Extractables (625/8270) 9
Free Chlorine Res:. mg/L 14. Chlorination Disinfection Byproducts (551) (14/GC/MS Semivolatile Unknown Scan
Total Chlorine Res: mg/L 15. Haloacetic Adds (552) 15. 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)
Mtalo at
1. Color 20. Acidity 39. Aluminum 59. Potassium
2. Turbidity 21. Alkalinity, as CaCO3 40. Antimony 60. Selenium’
3. pH
4. Conductivity
22. Bromide
23. Bromate/Chlorate/Chlorite
41. Arsenic
42. Barium
61. Silver
62. Sodium ; It’
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 CaCOs
28. Nitrogen, Ammonia as N 47. Calcium, Ca+2
E6"Metals/cN
9. Chemical Oxygen Demand
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.Pesticides/PCB‘s
13Solids, 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
35. Phosphorus, Ortho as P 54 Magnesium 71 TCLP-Metals
16. Solids, Total 72. TCLP-Pesticides
17. Solids, Total Dissolved 36. Sulfates 55 Manganese
37. Surfactants 56. Mercury 73.TCLP-Herbicides
18. Solids, Total Volatile 74. TCLP-Volatiles
19. Other:________________ 38. UV254 57 Molybdenum
58. Nickel
75.TCLP-BNA’S
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NYC-WTC_000027648
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