NYC 9/11 Public Portal Document
1* ACCo,
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
Westchester
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govcom 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:
& 2848 C 2240 2-
S Form A-70 (rev.10/01)
Sample Type (circle one): P- ISSH P- IS B1
1.Potable 3. Non Potable Treated Bottle #’s: C-0094L K, 4 0276 L ■ 465 K6e
2. Non Potable 4. Other___________ Chain of Custody?Yes No K ‘I C 7
Time/Date Collected: GH HD 2-.3 -02 Comments:
Collected By: We 0 nec Agency Code: PWS #:______ Source ID: Type Descriptor:
Collected From: Bill to:
Location’s/Individual’s Name NVC Name/Company
G
Street 1 WeslaveO-:uo Street________
City/St/Zip Valhall NV iosS City/St/Zip
Identification of Source Phone#: Fax#:
Collection Point D @, | 1 8
CA,CH, BI? Check#: Amount$
BACTERIOLOGICAL ANALYSIS Lab#:
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) LGC/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 -------------------
_UCMRList1
RADIOCHEMICAL ANALYSIS MtBE Only (524)
Radon
Other____________________
INORGANIC ANALYSIS REQUESTED - Lab#:
__ Color Acidity
2 /
L. Aluminum __ Potassium
__ Turbidity Alkalinity £. Antimony — Selenium
_ pH Bromide •. Arsenic 12 Silver
__ Conductivity __ Bromate/Chlorate/Chlorite • Barium __ Sodium
Corrosivity (temp: °C) __ Chloride L. Beryllium • Thallium
_ BOD (5 day) __ Cyanide __ Boron __ Vanadium
__ Carbonaceous BOD (5 day) __ Fluoride 22 Cadmium 4. Zinc
__ Soluble BOD (5 day) __ Hardness, Total as CaC03 Calcium, as CaCOs
__ Chemical Oxygen Demand CLP
__ Nitrogen, Ammonia as N __ Calcium, Ca*2
__ Dissolved Oxygen __ Nitrogen, Nitrate as N LChromium, Total __ Metals/CN
__ Total Organic Carbon __ Volatiles
Nitrogen, Nitrite as N __ Chromium, Hexavalent
__ Total Organic Halides __ Semi-violatiles
Nitrogen, Total Kjeldahl as N — Cobalt
__ Solids, Percent (%) __ Pesticides/PCB’s
__ Oil and Grease Copper
__ Solids, Settleable Phenol i.Iron TCLP
__ Solids, Suspended Phosphorus Total as P •Lead
__ Solids, Total __ TCLP-Metals
__ Phosphorus, Ortho as P _ Magnesium __ TCLP-Pesticides
__ Solids, Total Dissolved __ Sulfates — Manganese
__ Solids, Total Volatile _TCLP-Herbicides
Surfactants • Mercury . TCLP-Volatiles
— Other: A_______ _ UV254 ‘ Molybdenum __ TCLP-BNA’s
t. Nickel
NYC-WTC_000038694
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