NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM \ACCO,
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.com WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
(914)231-1620 Fax (914) 231-1772
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NYS-ELAP No. 10108
Time/Date Set: Form A-70 (rev.10/01)
Sample Type (circle one): eSu '
(1. Potable) 3. Non Potable Treated Bottle
2. Non Potable 4. Other Chain of Custody? Yes No
Time/Date Collected:_ ____ ; 4 21 =(2 Comments:
Collected By: N : E ooc Agency Code: PWS #:________ Source ID: Type Descriptor:
Collected From: Bill to:
Location’s/Individual's Name Name/Company
Street________________________________________ Street
City/St/Zip__________________________________ ___ City/St/Zip
Identification of Source________ __________________ Phone#: Fax#:
Collection Point____ ots_________________
CA,CH, BI? Check#: Amounts
BACTERIOLOGICAL ANALYSIS Lab#: 15A2)
V
Lab#:________ ____ _________ _
ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS
__ Heterotrophic Plate Count
(hemodialysis & all others) Trihalomethanes (524) __ Purgeable Halocarbons (624/8260)
Coliform P/A (Public supplies) __ Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260)
__ Coliform MPN (priv well, raw, stp) __ Volatile Aromatics (524) __ Acrolein & Acrylonitrile (8260)
__ Fecal Coliform (all samples) Total Trihalomethane Potential (510) Organochlorine Pesticides (608/8081)
_ Microscopic __ Microextractables (504) PCB's (Arochlors) (608/8081)
__ Macroscopic Pesticides/PCB screen (508) _ Herbicides (SM18/6630,8151)
_ API __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SM18/6630)
_ Other: _ _______________ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13)
__ Pesticides (525) __ Glycols in Water
Refrigerated?yes no __ Carbamate Pesticides (531) — Acid Extractables (625/8270)
Chlorinated:? yes no Glyphosate (547) _ . Base Neutral Extractables (625/8270)
__ Diquat (549) X GC/MS Unknown Scan
Free Chlorine Res: - mg/L Chlorination Disinfection Byproducts (551) _ Phthalates (606MS)
Total Chlorine Res: _ mg/L __ Haloacetic Acids (552) Other:______________ _ _____ ___ —
__ Other Pesticides (SM 18/6630)
PH ,
_UCMR List 1
RADIOCHEMICAL ANALYSIS MtBE Only (524)
Radon
__ Other____________________
INORGANIC ANALYSIS REQUESTED - Lab#:
__ Color Acidity X Aluminum _ Potassium
__ Turbidity Alkalinity • Antimony • Selenium
_ pH Bromide •Arsenic • Silver
Conductivity __ Bromate/Chlorate/Chlorite Barium _ .Sodium
Corrosivity (temp: °C) __ Chloride Y Beryllium • Thallium
_ BOD (5 day) Cyanide Boron __ Vanadium
__ Carbonaceous BOD (5 day) Fluoride Cadmium __ Zinc
Soluble BOD (5 day) __ Hardness, Total as CaCO3
__ Chemical Oxygen Demand __ Nitrogen, Ammonia as N
__ Calcium, as CaCOa
__ Calcium, Ca+2
CLP
__ Dissolved Oxygen __ Nitrogen, Nitrate as N MChromium, Total Metals/CN
__ Total Organic Carbon __ Nitrogen, Nitrite as N __ Volatiles
_ Chromium, Hexavalent
__ Total Organic Halides X Cobalt __ Semi-violatiles
__ Nitrogen, Total Kjeldahl as N
Solids, Percent (%) __ Pesticides/PCB’s
__ Oil and Grease x Copper
__ Solids, Settleable __ Phenol M Iron
__ Solids, Suspended • Lead TCLP
__ Phosphorus Total as P
_ Solids, Total _TCLP-Metals
__ Phosphorus, Ortho as P __ Magnesium
Solids, Total Dissolved __ TCLP-Pesticides
_ Sulfates • Manganese
__ Solids, Total Volatile __ Surfactants -/Mercury
_TCLP-Herbicides
V Other: SY__________ _ AZ Molybdenum _ TCLP-Volatiles
_ UV254
V Nickel TCLP-BNA’s
NYC-WTC_000038374
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