NYC 9/11 Public Portal Document
d ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM <%
WESTCHESTER COUNTY LABORATORIES AND RESEARCH $
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2 Dana Road, Valhalla, New York 10595 G. ■ I 1
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(914) 231-1620 Fax (914) 231-1772
NYS-ELAP No. 10108
Time/Date Set: Form A-70 (rev. 10/01)
Sample Type (circle one):
P
29-34
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(52—’ 33c 3 \ A S14- 3 44
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(1. Potable) 3. Non Potable Treated Bottle #’s: < 616612.
2. Non Potable 4, Other Chain of Custody? Yes No
Time/Date Collected: O • 2.0 L. 31 242. Comments:
Collected By: “ C t k w & 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 S
CA,CH, Bl? Check#: Amounts
BACTERIOLOGICAL ANALYSIS Lab#: 70 / 1 / 7
Lab#:_______________________ J / CA /
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) Oth e r:___________
pH ___________ __ Other Pesticides (SM18/6630)
_UCMR List 1
RADIOCHEMICAL ANALYSIS __ MtBE Only (524)
Radon
Other____________________
INORGANIC ANALYSIS REQUESTED - Lab#:
Color Acidity V Aluminum __ Potassium
__ Turbidity __ Alkalinity • Antimony v Selenium
_ PH Bromide • Arsenic — Silver
__ Conductivity Bromate/Chlorate/Chlorite / Barium __ Sodium
Corrosivity (temp: °C) Chloride • Beryllium / Thallium
_ BOD (5 day) __ Cyanide __ Boron Vanadium
Carbonaceous BOD (5 day) Fluoride Cadmium X Zinc
__ Soluble BOD (5 day) __ Hardness, Total as CaCO3 __ Calcium, as CaCOs CLP ;
__ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*2
__ Dissolved Oxygen Nitrogen, Nitrate as N _ Metals/CN
M Chromium, Total
__ 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 • Iron TCLP
__ Solids, Suspended __ Phosphorus Total as P Z Lead
__ Solids, Total _TCLP-Metals
__ Phosphorus, Ortho as P _ _ Magnesium
__ Solids, Total Dissolved __ TCLP-Pesticides
Sulfates / Manganese
__ Solids, Total Volatile • Mercury _TCLP-Herbicides
Surfactants
M Other: 2 ; 1____________ __ TCLP-Volatiles
_ UV254 7 Molybdenum
__ TCLP-BNA’s
• Nickel
NYC-WTC_000039199
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