NYC 9/11 Public Portal Document
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ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
tester
lbv.com WESTCHESTER COUNTY LABORATORIES AND RESEARCH
1 2 Dana Road, Valhalla, New York 10595
(914) 593-5575
ft e/Date Set:
NYS-ELAP No. 10108
Form A-70 (rev.1/96)
Sample Type (circle one):
Bottle #s: t_____ ‘s
1. Potable :3. Non Potable Treated *---------- —
2. Non Potable -4. Other__________ Chain of Custody? yes no
Time/Date Collected: 1 -10 1 I
080+ Comments:
Collected By: eus(5 Agency Code: _ Source ID: Type Descriptor
Collected From: Bill to:
Location’s/Individual’s Name H * Name/Company _
Street_____________________ Street________
City/St/Zip__________________ City/St/ZIp
Phone#: . Fax#:
Identification of Source
Collection Point 2 0 G \D 28809 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 Pesticides (507) 6. PCB’s (Arochlors) (608/8081)
(•Macroscopic
WAPI 6 Pesticides/PCB screen (508)
8. PCB as Decachlorobiphenyl (508A)
7. Methoprene (616)
8. Herbicides (EPA1978/8151)
8. Other:__________ _ ____ __ 9. Herbicides (515) 9. Pesticides (SM18/6630)
Refrigerated? yes no (10) Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13)
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) d4./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)
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INORGANIC ANALYSIS REQUESTED - Lab#:
(circle tests)
lrawo=nrpqc"yy" — ado 17. Pesticides/PCB’s (DEF)
18. Other ___________ '
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—
1. Color 20. Acidity 39. Aluminum 59. Potassium
2. Turbidity 21. Alkalinity, as CaCO3 40. Antimony 60. Selenium i
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
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 50.Cobalt 69. Pesticides/PCB’s
13. Solids, Percent (%) 32. Oil an Grease 51. Copper 70. Disk Deliverables
(. 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
36. Sulfates 55 Manganese
72.TCLP-Pesticides
17. Solids, Total Dissolved 73.TCLP-Herbicides
18. Solids, Total Volatile 37. Surfactants 56. Mercury
38. UV254 57 Molybdenum 74. TCLP-Volatiles
19. Other:________________ 75.TCLP-BNAs
58. Nickel
NYC-WTC_000027729
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