NYC 9/11 Public Portal Document
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ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
III
ime/DateSet:
WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
(914)593-5575
\ ■
NYS-ELAP No. 10108
Form A-70-(rev. 1/96)
Sample Type (circle one): --- K *79/. 7 / > • 2770 92722,7777 '
1 Potable 3. Non-Potable Treated
Bottle KZy s t___ ___ 7 ---- .---- .-- , 4
2. Non-Potable 4. Other____ Chain of Custody? .yes .no
✓
Time/Date Collected: 130 Comments:
Collected By: ~ " 2 Agency Code: PWS#:_________ Source ID: .Type Descriptor:.
Collected From: Bill to:
Location’s/Individual’s Name. •l 21 _
Street__________________ Street__________
_ City/St/Zip
Identification of Source____ DP# Phone#:_ -Fax #:
Collection Point. 312 91 .30879 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) 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 A Pesticides (507) 6. PCB's (Arochlors) (608/8080)
6. Macroscopic 7) Pesticides/PCB screen (508) 7. Herbicides (SM-18/6640; 8151)
•APE 8. PCB as Decachlorobiphenyl (508A) 8. Other Pesticides (SM-18/6630)
Br Other:______________ • Herbicides (515) 9. Petroleum Hydrocarbon Scan (310-13)
Pesticides (525) 10. Glycols in Water
Refrigerated? yes no Carbamate Pesticides (531) 11. Acid Extractables (625/8270) '
12. Glyphosate (547) 12 Base Neutral Extractables (625/8270) .
Chlorinated?: yes no 13. Diquat (549) i(13/GC/MS Unknown Scan
14. Chlorination Disinfection Byproducts (551) 14. Purgeable Halocarbons (DEF)
S
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) t
‘x% yMals &
oe
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 1
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 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-volatiles
12. Total Organic Halides 31. Nitrogen, Total Kjeldahl as N 50. Cobalt 69. Pesticides/PCB’s
4 33 Solids, Percent (%) 32. Oil and Grease 51. Copper 70. Disk Deliverables
C 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-Volatiles
19. Other:_________________ 38. UV254 57. Molybdenum 75. TCLP-BNA’s
58. Nickel
NYC-WTC_000027724
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