NYC 9/11 Public Portal Document
4
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM tACCo,,*
* Westchester
y govcom WESTCHESTER COUNTY LABORATORIES AND RESEARCH 5%
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2 Dana Road, Valhalla, New York 10595 ti 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): — " -60
i 1 .Potable 3. Non Potable Treated Bottle #’s: .— /26/ ‘ . J
2. Non Potable 4. Other___________ Chain of Custody? Yes No
Time/Date Collected: Comments:
Collected By: . ■ • 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
CA.CH, Bl? Check#: Amounts
BACTERIOLOGICAL ANALYSIS Lab#: //_
Lab#:_______________________ 3 7 ‘ A
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 gel Microextractables (504) __ PCB’s (Arochlors) (608/8031)
Macroscopic Pesticides/PCB screen (508) __ Herbicides (SM18/6630,8151)
_ API __ PCB as Decachlorobiphenyl (508A) Other Pesticides (SM 18/6630)
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 (SM18/6630)
pH ___________
UCMR List 1
RADIOCHEMICAL ANALYSIS MtBE Only (524)
Radon
Other____________________
INORGANIC ANALYSIS REQUESTED - Lab#:
Color __ Acidity 'Aluminum Potassium
__ Turbidity __ Alkalinity = Antimony — 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 15.day) __ Fluoride Cadmium '.Zinc
_ Soluble BOD (5 day) __ Hardness, Total as CaCO3 Calcium, as CaCOs
__ Chemical Oxygen Demand CLP
_ Nitrogen, Ammonia as N Calcium, Ca+2
__ Dissolved Oxygen __ Nitrogen, Nitrate as N _ Metals/CN
Chromium, Total
__ Total Organic Carbon __ Nitrogen, Nitrite as N __ Volatiles
Chromium, Hexavalent
Total Organic Halides __ Nitrogen, Total Kjeldahl as N __ Semi-violatiles
t Cobalt
__ Solids, Percent (%) Pesticides/PCB’s
Oil and Grease _ Copper
__ Solids, Settleable Phenol Iron
__ Solids, Suspended TCLP
Phosphorus Total as P _ Lead
__ Solids, Total _TCLP-Metals
Phosphorus, Ortho as P __ Magnesium
__ Solids, Total Dissolved __ TCLP-Pesticides
__ Sulfates 2 Manganese
__ Solids, Total Volatile _TCLP-Herbicides
__ Surfactants Mercury
_ Other: ._________ TCLP-Volatiles
UV254 _ Molybdenum
TCLP-BNA’s
Nickel
NYC-WTC_000039209
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