NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
ster WESTCHESTER COUNTY LABORATORIES AND RESEARCH
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2 Dana Road, Valhalla, New York 10595
(914)593-5575 , ,
krni-tu - : ) NYS-ELAP No. 10108
Time/Date Set: ,Torm A-70 (rev. 1/96)
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Sample Type (circle one): V ro, f t
Q/potable 3. Non Potable Treated Bottle #’s:( i ; - ’ j. ' i
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2. Non Potable 4. Other Chain of Custody?. yes no
Time/Date Collected: ’ f ______ Comments:
Collected By: 'Y. 11 / u Agency Code: PWS #:________ Source ID: Type Descriptor:
Collected From: Bill to:
1,ocation’^ndividuars Name C - Name/Company
Street f » Street_________
r'City/St/Zip lA I I QS ST City/St/Zip
J Identification of Source________________________ Phone#:_______ Fax#:
;Collection Point CQo 6^ (f / )_____
CA.CH, Bl? Check#: Amounts.
BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS
Lab#: _ _____________________ Lab#:________________________
’ (circle tests) (circle tests)
/I ; Heterotrophic Plate Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260)
Count (hemodialysis & all others) ,'2) 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) R Microextractables (504) 5. Organochlorine Pesticides (608/8081)
5«44icroscopic 6. Pesticides (507) 6. PCB’s (Arochlors) (608/8081)
6. Macroscopic' (77 Pesticides/PCB screen (508) 7. Methoprene (616)
7. API 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPAI 978/8151)
8. Other:____________________ / 9. Herbicides (515) 9. Pesticides (SMI8/6630)
04 Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13)
Refrigerated?yes no
41/ Carbamate Pesticides (531) 11. Glycols
Chlorinated:? ves,, no ;12. Glyphosate (547) 12. Acid Extractables (625/8270)
(13^ Diquat (549) 13. Base Neutral Extractables (625/8270)
ree Chlorine Res:. mg/L '14. Chlorination Disinfection Byproducts (551) 14. GC/MS Semivolatile Unknown Scan
pbtal Chlorine Res: mg/L 15. Haloacetic Acids (552) 15. Purgeable Halocarbons (DEF)
16. Pesticides (SMI 8/6630) 16. Purgeable Aromatics (DEF)
17. Petroleurp/Hydrocarbon Scan (310-13) 17. Pesticides/PCB’s (DEF)
i^l^. Other: SmY i P 18. Other:.
INORGANIC ANALYSIS REQUESTED - Lab#:
(circle tests)
1. Color 20. Acidity Aluminum 5^ Potassium
2. Turbidity 21. Alkalinity, as CaCOa 4O.j Antimony 60^Selenium
1 3. pH 22. Bromide 41.Ursenic 61.iSilver
I 4. Conductivity
5. Corrosivity (temp: .®C)
23. Bromate/Chlorate/Chlorite
24. Chloride
42. Barium
*4§^eryllium
62. Sodium
63. Thallium
6. BOD (5 day) 25. Cyanide 44. Boron 64. Vanadium
7. Soluble BOD (5 day) 26. Fluoride ^Cadmium \65/Zinc
8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOa 46. Calcium, as CaCOs CLP
9. Chemical Oxygen Demand 28. Nitrogen, Ammonia as N ^Calcium, Ca*®
66. Metals/CN
10. Dissolved Oxygen 29. Nitrogen, Nitrate as N @ Chromium, 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 ^Cobalt 69. Pesticides/PCB’s
13. Solids, Percent (%) 32. Oil an Grease '^Copper
70. Disk Deliverables
14. Solids, Settleable 33. Phenol 52S Iron
TCLP
15. Solids, Suspended 34. Phosphorus Total as P 53 Lead
54 Magnesium 71.TCLP-Metals
16. Solids, Total 35. Phosphorus, Ortho as P
72.TCLP-Pesticides
17. Solids, Total Dissolved 36. Sulfates 55 Manganese
73. TCLP-Herbicides
18. Solids, Total Volatile 37. Surfactants 56. Mercury
19. Other: ~ i; 38. UV254 57 MolybdenLtfn 74. TCLP-Volatiles
'■58j Nickel 75.TCLP-BNA’s
NYC-WTC_000063082
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