NYC 9/11 Public Portal Document
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ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
OSTPr
ovcom WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595 Ub
I
(914) 593-5575
NYS-ELAPNo. 10108
10o ate Set: 5*
Y
R w |_ Form A-70 (retuse
Sample Type (circle one): qars> T9*pp99979 g
Bottle #s: _ ________________________________ —_
1. Potable 3. Non Potable Twated
2. Non Potable 4. Other ___ __________________ Chain of Custody?yes no
Time/Date Collected: /ofie | 206 /_______ /19. Comments^ 2__
Collected By: \4 No _ _______ Agency Code:____ _ Source ID: .Type Descriptor.
Collected From: Bill to:
Location’s/ndividual’s Name Name/Company
Street________________ Street
City/St/Zip____________ City/St/Zip
Identification of Source -_______ pt Phone#: Fax#
Collection Point______ _
BACTERIOLOGICAL ANALYSIS
.
16
1
.-032
r ep
CA.CH, _
ORGANIC POTABLE ANALYsiSli1 - 73
3*
Check 1 Amounts.
ORGANIC NONPOTABLE/SOLID ANALYSIS
Lab#:____________________ Lab#_________ —_
(circle tests) (circle tests) ynki
1. Trihalomethanes (524)
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1. Purgeable Halocarbons (624/8260)
8
1. Heterotrophic Plate v
Count (hemodialysis & all others) 2. Volatile Halocarbons 4(524) 1
$
5 2. Purgeable Aromatics (624/8260) 93
2. Coliform P/A (public supplies) 13 Volatile Aromatics (524) 1 t 3. Acrolein A Acrylonitrile (624)
2.
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) J
6.croscopic (7) Pesticides/PCB screen (508) 7. Methoprene (616)
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. 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) C3
18. Other._______________________ 18. Other.________________
INORGANIC ANALYSIS REQUESTED - Lab#:
(circle tests) 9 /loka
1. Color 20. Acidity 39. Aluminum 59. Potassium
2. Turbidity 21. Alkalinity, as CaC03 40. Antimony 60. Selenium 1
3. pH 22. Bromide 41. Arsenic 61. Silver i
4. Conductivity 23. Bromate/Chlorate/Chlorite 42. Barium 62. Sodium
5. Corrosivity (temp: / aC) 24. Chloride 43. Beryllium 63. Thallium V
6. BOD (5 day) ’ 0 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-violatlles
12: Total Organic Halides 31. Nitrogen, Total Kjeldahl as N SO.Cobalt 69. Pesticides/PCB’s
12Solids, Percent (%) 32. Oil an Grease 51. Copper 70. Disk Deliverables
CSolids, 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-Herblddes
37. Surfactants 56. Mercury
18. Solids, Total Volatile
38. UV254 57 Molybdenum 74. TCLP-Volatiles
19. Other ___ ____________ 75. TCLP-BNA’s .
58. Nickel 2
5,
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NYC-WTC_000027807
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