NYC 9/11 Public Portal Document
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ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
Jrcherter county 614)5938575 -E42 NYS-ELAP No. 10108
“he/Date Set:_______
—:» 004—24125 . ) Form A-70 (rev. 1/96)
Sample Type (circle one): 22
Ae 2.141 0023,47
1. Potable 3. Non-Potable Treated Bombs? 226,2025 7 ...2 7
2. Non-Potable 4. Other ______________ Chain of Custody?_____ yes no
Time/Date Collected: ' h. > 0 81 43 Comments:_____________
y.-
Collected By:".’ - : y
// r Agency Code: PWS#:________ “Source ID:. .Type Descriptor:
3.
Collected From: Bill to:
Location’s/Individual’s Name. Altylelo Name/Company__
Street__________________ Street_________
City/St/Zip_______________ City/St/Zip______
Identification of Source_ Phone#:_ -Fax #:
Collection Point.
“2, CA, CH, Bl? ' Check#: Amounts.
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BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES . J ORGANIC NONPOTABLE/SOLID ANALYSES
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Lab#:______________________ Lab#:________________ ;________ —
(circle tests) (circle tests)
1. Heterotrophic Plate 1 Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260)
1 2. Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260) $p
Count (hemodialysis & all others)
2. Coliform P/A (public supplies) -3. Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624) is
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)
6. PCB’s (Arochlors) (608/8080)
5. Microscopic
SP;
6. Macroscopic G Pesticides (507)
Pesticides/PCB screen (508)
8. PCB as Decachlorobiphenyl (508A)
7. Herbicides (SM-18/6640; 8151)
8. Other Pesticides (SM-18/6630)
“Other:________________ 9. Herbicides (515)
(10. Pesticides (525) 1
1**
9. Petroleum Hydrocarbon Scan (310-13)
10. Glycols in Water
Refrigerated? yes no 11. Carbamate Pesticides (531)
j:
11. Acid Extractables (625/8270)
12. Glyphosate (547) 12. Base Neutral Extractables (625/8270)
Chlorinated?: yes no 13. Diquat (549) 13. GC/MS Unknown Scan
14. Chlorination Disinfection Byproducts (551) 14. Purgeable Halocarbons (DEF)
Free Chlorine Res:. mg/L 15. Haloacetic Acids (552) 15. Purgeable Aromatics (DEF) ,3
16. Other Pesticides (SM-18/6630) ”. - 16. Pesticides (DEF) i 5
Total Chlorine Res: mg/L 17. Petroleum/Hydrocarbon Scan (310-18) 17. PCB’s (Arochlors) (DEF) i
pH
. .
if
g. 1A y 7
INORGANIC ANALYSES REQUESTED - Lab#:.
(circle tests)
1. Color 4 20. Acidity
ct W 1 f yU2
39. Alumin
0
59. Potassium
2. T urbidity 21. Alkalinity, as CaCO3 40. Antimoi 60. Selenium
3. pH 22. Bromide 41. Arsenidg 61. Silver
4. Conductivity 23. Bromate/Chlorate/Chlorite 42. Barium 62. Sodium
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 CaCOs 46. Calcium, as CaCO3 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
(s Solids, Percent (%) 32. Oil and Grease 51. Copper 70. Disk Deliverables
' U Solids, Settleable 33. Phenol 52. Iron ISLE
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. Molybdepum 75. TCLP-BNA’S
s 58. Nickel P ‘_____
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NYC-WTC_000027811
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