NYC 9/11 Public Portal Document
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ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
ster WESTCHESTER COUNTY LABORATORIES AND RESEARCH
com 2 Dana Road, Valhalla, New York 10595
(914) 593-5575
@ne/DateSeti____________ NYS-ELAP No. 10108
Form A-70 (rev. 1/96)
Sample Type (circle one): ((g4,086-,9758
1. Potable 3. Non Potable Treated Bottle #s: 267 388 Z /214
2. Non Potable 4. Other . t______________________ Chain of Custody?yes no
Time/Date Collected: //// 05 7 Comments:
Collected By: B.Getuk— Agency Code: z 0/FP _ Source ID: .Type Descriptor:
Collected From!- 39 * _ Bill to:
Location’s/individual’s Name /n Name/Company
Street______________________ Street_______
City/St/Zip___________________ City/St/Zip
Identification of Source Phone#: Fax#:
Collection Point__ # 46760 20880 CA,CH, Bl? Check#: Amounts.
BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS
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 (625/8270)
4. Fecal Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8081)
5. Microscopic 6. Pesticides (507) 6. PCB’s (Arochlors) (608/8081)
, ^Macroscopic 02 Pesticides/PCB screen (508) 7. Methoprene (616)
WAPI 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151)
8. Other:__________ _ ______ 9. Herbicides (515) 9. Pesticides (SM18/6630)
(0) Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13)
Refrigerated? yes no
11. Carbamate Pesticides (531) 11. Glycols
Chlorinated:? yes no 12. Glyphosate (547) 12. Acid Extractables (625/8270)
13. Diquat (549) 13. Base Neutral Extractables (625/8270)
Free Chlorine Res:. mg/L 14. Chlorination Disinfection Byproducts (551) (4./GC/MS Semivolatile Unknown Scan
Total Chlorine Res: mg/L 15. Haloacetic Acids (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)
INORGANIC ANALYSIS REQUESTED - Lab#:
(circle tests)
1. Color
2. Turbidity
20. Acidity
18. Other
21. Alkalinity, as CaCOs
aes 39. Aluminum
40. Antimony
' 18.Other_
—
59. Potassium
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
25. Cyanide
43. Beryllium
44. Boron
63. Thallium
64. Vanadium
6. BOD (5 day)
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 50.Cobalt 69.Pestlcides/PCB’s
13. Solids, Percent (%) 32. Oil an Grease 51. Copper 70. Disk Deliverables
( Solids, Settleable 33. Phenol 52. Iron TCLP
"5. 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
56. Mercury 73. TCLP-Herbicides
18. Solids, Total Volatile 37. Surfactants 74. TCLP-Volatiles
19. Other:________________ 38. UV254 57 Molyodenum 75.TCLP-BNA’S
58. Nickel
bicat 1..
NYC-WTC_000027727
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