NYC 9/11 Public Portal Document
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ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
ster WESTCHESTER COUNTY LABORATORIES AND RESEARCH
)vcom
2 Dana Road, Valhalla, New York 10595
(914) 593-5575
NYS-ELAP No, 10108
iime/Date Set;
/ V/j?) Fornri A-70 (rev.1/96)
t
^^nplelype (circle one): Y J'.', "•bY ‘'• (
I Impotable 3. Non Potable Treated Bottle #’^: 3^/
2. Non Potable 4. Other Chain of Custody? yes no
'Time/Date Collected; ' I /.Y o I / i (3_______ Comments:
Collected By; Agency Code; PWS #:______ _ Source ID: Type Descriptor:
Collected From: Bill to:
Location’s/lndividual’s Name kiV C -- iX' Name/Company
Street Street_________
City/St/Zip City/St/Zip
Identification of Source_______ __________ Phone#:_______ Fax#:
Collection Point X
CA,CH, Bl? Check#: Amounts.
BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS
Lab#:___________ __ ________ Lab#:________________________
(circle tests) (circle tests)
1. Heterotrophic Plate (Ja Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260)
Count (hemodialysis & all others) ‘*2.' Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260)
A 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)
i; L Fecal Coliform (all samples)
i. Microscopic
i. Macroscopic
6 API
t' Lother:________________
, 'T. )Microextractables (504)
K Pesticides (507)
<7,JPesticides/PCB screen (508)
8. PCB as Decachlorobiphenyl (508A)
' S. Herbicides (515)
5. Organochlorine Pesticides (608/8081)
6. PCB’s (Arochlors) (608/8081)
7. Methoprene (616)
8. Herbicides (EPAI 978/8151)
9. Pesticides (SMI 8/6630)
L I 'rigerated?yes no
.’YO. 'Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13)
'll. Carbamate Pesticides (531) 11. Glycols
lorinated:? yes no f 12^ Glyphosate (547) 12. Acid Extractables (625/8270)
(l3?Diquat (549) 13. Base Neutral Extractables (625/8270)
e Chlorine Res:. mg/L 14. Chlorination Disinfection Byproducts (551) 14. GC/MS Semivolatile Unknown Scan
al Chlorine Res: mg/L 15. Haloacetic Acids (552) 15. Purgeable Halocarbons (DEF)
16. Pesticides (SMI8/6630) 16. Purgeable Aromatics (DEF)
17. Petroleuj^Hydrocarbon Scan (310-13) 17. Pesticides/PCB’s (DEF)
^8. Other: h W -4- j>. n v . -1 18. Other:_________________________
KJ lORGANIC ANALYSIS REQUESTED - Lab#r^i
yR (circle tests) 9
Ob - Turbidity
20. Acidity
21. Alkalinity, as CaCOs
39u Aluminum
40 Antimony
/5&1. Potassium
6O.|Selenidm
II-
, ■|R4. Conductivity
22. Bromide
23. Bromate/Chlorate/Chlorite
41 Arsenic
42. Barium
61. Silver;
62. Sodium ■'y
«5. Corrosivity (temp:__ ®C) 24. Chloride ,^Beryllium 63. Thallium
I BOD (5 day) 25. Cyanide Boron 64. Vanadium
Soluble BOD (5 day) 26. Fluoride ^SCadmium Kesyzinc ________
Wfe Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOa ^Calcium, as CaCOs CLP
I W» Chemical Oxygen Demand 28. Nitrogen, Ammonia as N ^Calcium, Ca^^
66. Metals/CN
fflilO. Dissolved Oxygen 29. Nitrogen, Nitrate as N @Chromium, Total 67. Volatiles
^^1. Total Organic Carbon 30. Nitrogen, Nitrite as N Chromium, Hexavalent 68. Semi-violatiles
®12. Total Organic Halides 31. Nitrogen, Total Kjeldahl as N '^Cobalt 69. Pesticides/PCB’s
>13. Solids, Percent (%) 32. Oil an Grease 51 Copper 70. Disk Deliverables
>14. Solids, Settleable 33. Phenol 52, Iron
34. Phosphorus Total as P 53 Lead T£LP
!15. Solids, Suspended
35. Phosphorus, Ortho as P 54 Magnesium 71 TCLP-Metals
46. Solids, Total
36. Sulfates 55 Manganese 72.TCLP-Pesticides
47. Solids, Total Dissolved
37. Surfactants 56. Mercury 73. TCLP-Herbicides
‘ 18. Solids, Total Volatile
19. Other; '7', 38. UV254 57 Molybdenum 74. TCLP-Volatiles
4- Nickel 75.TCLP-BNA’s
NYC-WTC_000063081
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