NYC 9/11 Public Portal Document
. +0ACcG,
Nestc ester
ovcom
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
WESTCHESTER COUNTY LABORATORIES AND RESEARCH
*
2 Dana Road, Valhalla, New York 10595 —
IX
(914) 231-1620 Fax (914) 231-1772
Time/Date Set: C-\uAU A NYS-ELAP No. 10108
Form A-70 (rev.10/01)
Sample Type (circle one):
------------------------ ?—21*
Bottle #’s: & -
1. Potable 3. Non Potable Treated 2/4 1 933
2. Non Potable
Time/Date Collected:
Collected By: k
4. Other
— _ * 3
—A
l..
_______________
A 9 I CL Agency Code:
(u/ Chain of Custody?
Comments:
Yes No
PWS #:________ Source ID: Type Descriptor.
Collected From: Bill to:
Location’s/Individual’s Name Name/Company _
Street 1 Street_________
City/St/Zip______________ City/SVZip
Identification of Source Phone#:_______ Fax#:
Collection Point 00s% CA.CH, Bl? Check#: Amount?.
BACTERIOLOGICAL ANALYSIS Lab#:
Lab#:_______________________
ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS
__ Heterotrophic Plate Count
(hemodialysis & ail 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) _ Pesticides (608/8081)
__ Microscopic __ _ (504) _ PCB's (Arochlors) (608/8081)
Macroscopic _ 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) __ GC/MS Unknown Scan
Free Chlorine Res:, . mg/L __ Chlorination Disinfection Byproducts (551) Phthalates (606MS)
Total Chlorine Res: . mg/L _ Acids (552) __ Other:_____ :__________ .___________
pH ___________ _ Other Pesticides (SM18/6630)
_UCMRList1
RADIOCHEMICAL ANALYSIS _MtBE Only (524)
Radon
_ Other____________________
INORGANIC ANALYSIS REQUESTED - Lab#:
__ Color __ Acidity
5-22 — Aluminum __ Potassium
Turbidity __ Alkalinity . Antimony — Selenium
_ PH __ Bromide - Arsenic • Silver
Conductivity __ Bromate/Chlorate/Chlorite . Barium __ Sodium
__ Corrosivity (temp:.
BOD (5 day)
.°C) __ Chloride V Beryllium — Thallium
Cyanide Boron _ Vanadium
Carbonaceous BOD (5 day) __ Fluoride Cadmium —Zinc
_ Soluble BOD (5 day) __ Hardness, Total as CaCO3 Calcium, as CaCOs
Chemical Oxygen Demand __ Nitrogen, Ammonia as N —Calcium, Ca*2
CLP
Dissolved Oxygen ___Nitrogen, Nitrate as N —Chromium, Total _ Metals/CN
__ Total Organic Carbon ___ Nitrogen, Nitrite as N __ Volatiles
__ Chromium, Hexavalent
__ Semi-violatiles
__ Total Organic Halides Nitrogen, Total Kjeldahl as N e Cobalt
Solids, Percent (%) __ Oil and Grease “ Copper _ Pesticides/PCB’s
__ Solids, Settleable __ Phenol —Iron TCLP
Solids, Suspended __ Phosphorus Total as P “Lead
Solids, Total __ Phosphorus, Ortho as P _TCLP-Metals
Magnesium
Solids, Total Dissolved __ Sulfates — Manganese __ TCLP-Pesticides
__ Solids, Total Volatile Surfactants — Mercury _TCLP-Herbicides
— Other: _ UV254 __ TCLP-Volatiles
_ Molybdenum
TCLP-BNAs
LNickel
NYC-WTC_000038475
OCR can misread numbers and units. Confirm readings against the page image before using them.