NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
..WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
(914) 593-5575
NYS-ELAP No. 10108
Time/Date Set: /. .A > (r6v.1/96)
If' K,!.,- rfU'* r' * t ( i / 7 . t ,
Sample Type (circle one); ■j’W ^<37,b »
tebttie #’s:
/l potable 3. Non Potable Treated ' / ' / * < » ■' i • tit i
/
T2; Non Potable 4. Other________________ Chain of Custody? yes no
Time/Date Collected:: 'I' QI Comments:
Collected By: “si* Kr-O/ Agency Code; PWS #:________ Source ID: Type Descriptor;
Collected From: Bill to:
Location’s/lndividual’s Name Name/Company
street H bv . -
Street _ _______
City/St/Zip I/aIKkIU kI.V City/St/Zip
Identification of Source________________________ Phone#: _____ Fax#;
Collection Point bC I ______
I CA,CH, Bl? Check#: Amounts.
BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS
Lab#:________ _ _____________ Lab#:______________________
(circle tests) (circle tests)
1. Heterotrophic Plate Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260)
Count (hemodialysis & all others) Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260)
2. Coliform P/A (public supplies) Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624)
3. Coliform MPN (priv well, raw, stp) 4. Total Trihalomethane Potential (510) 4. Phthalates (625/8270)
4. Fecal Coliform (all samples) /S. )Microextractables (504) 5. Organochlorine Pesticides (608/8081)
ft Microscopic Ser Pesticides (507) 6. PCB’s (Arochlors) (608/8081)
n Macroscopic Pesticides/PCB screen (508) 7. Methoprene (616)
Iapi 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151)
K Other:____________________
Herbicides (515) 9. Pesticides (SMI8/6630)
^ Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13)
lefrigerated?yes no
Carbamate Pesticides (531) 11. Glycols
Jhlorinated:? yes___ no ,-^23 Glyphosate (547) 12. Acid Extractables (625/8270)
(13; Diquat (549) 13. Base Neutral Extractables (625/8270)
|ee Chlorine Res:. mg/L 14. Chlorination Disinfection Byproducts (551) 14. GC/MS Semivolatile Unknown Scan
il Chlorine Res: mg/L 15. Haloacetic Acids (552) 15. Purgeable Halocarbons (DEF)
16. Pesticides (SMI8/6630) 16. Purgeable Aromatics (DEF)
17. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB’s (DEF)
(I8^ther: SHfe 4 D text A 18. Other:________ __________
lORGANIC ANALYSIS REQUESTED - Lab#;
^^■Ffcircle tests)
1. Color 20. Aridity Aluminum 19 A Potassium!
2. Turbidity 21. Alkalinity, as CaCOs Antimony 60. ielenium
I
3. pH
4. Conductivity
5. Corrosivity (temp;.
6, BOD (5 day)
7. Soluble BOD (5 day)
?C)
22. Bromide
23. Bromate/Chlorate/Chlorite
24. Chloride
25. Cyanide
26. Fluoride
27. Hardness, Total as CaCOs
I \rsenic
3arium
beryllium
42rBoron
45^admium
ABTCalcium, as CaCOs
161. iilver
62. iodium
63. ■hallium
64. Vanadium
^S§;^inc j
8. Carbonaceous BOD (5 day) CLP
9. Chemical Oxygen Demand 28. Nitrogen, Ammonia as N ^T^alcium, Ca*^ 66. Metals/CN
10. Dissolved Oxygen 29. Nitrogen, Nitrate as N 48^hromium, Total
67. Volatiles
11. Total Organic Carbon 30. Nitrogen, Nitrite as N 49. Chromium, Hexavalent 68. Semi-violatiles
12. Total Organic Halides 31. Nitrogen, Total Kjeldahl as N S^obalt 69. Pesticides/PCB’s
13. Solids, Percent (%) 32. Oil an Grease ^fcopper
70. Disk Deliverables
14. Solids, Settleable 33. Phenol
5^ead TCLP
15. Solids, Suspended 34. Phosphorus Total as P
^Magnesium 71 TCLP-Metals
16. Solids, Total 35. Phosphorus, Ortho as P
72.TCLP-Pesticides
17. Solids, Total Dissolved 36. Sulfates ^^Manganese
S^Mercury 73.TCLP-Herbicides
18. Solids, Total Volatile , -— 37. Surfactants
19. Other: , 11 74. TCLP-Volatiles
38. UV254
75.TCLP-BNA’s
lickel
NYC-WTC_000063080
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