NYC 9/11 Public Portal Document
5 ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
ter
:com WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
(914) 593-5575
NYS-ELAPNo. 10108
Time/Date Set: Form A-70 (rev.1/96)
(circle one): 6? 67s', 6S76
3. Non Potable Treated Boimra: P-S7l^<R5^.?7?.
2. Non Potable 4. Other___________ Chain of Custody?___yes__ no
Time/Date Collected: Comments:
Collected By: m Agency Code: PWS#-._____ Source ID: Type Descriptor
Collected From: Bill to:
Location’s/lndividuars Naim. z> • *7 Name/Company
Street_____________ _ _______________ __________ Street...,_____
citv/stzziD * City/St/Zlp„
Identiflcation of -
(MMk.M«
BACTERioLC«icALAfUiS5Pl ORGANIC NQNPOTABLE/SOLID ANALYSIS
Lab#: '■ ■'
(circle tests) '
1. Heterotrophic Plate 1. Trlhalomethanes (524) 1. Purgeable Halocarbons (824/8260) '
Count (hemocSaiysls& alicrtlteis) 2.yolatile Halocarbons (524) 2. Purgeable Aromatics (624/8260)
2. Coliform P/A (public supplies) Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (824)
3. Coliform MPN (privwell, raw,stp) T Total Trihalomethane Potential (510) s' Or^rSotiS^eSSdes (608/8081)'
4. Fecal Coliform (all samples) 5. Microextractables (504)
5. Microscopic Pesticides (507) 6. PCB’s (Arochlors) (608/8081) ’
6. Macroscopic Pesticides/PCB screen (508) 7. Methcprene (616)
7. API PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151)
8. Other.______________ _ 9. Herbicides (515) 9. Pesticides (SM18/6630)
yes no (^Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13)
Refrigerated?
TT Carbamate Pesticides (531) 11. Glycols
Chlorinated:? yes no 12. Glyphosate (547) 12. Acid Extractables (625/8270)
13. Diquat (549) 13. Base Neutral Extractables (625/8270)
Free Chlorine Res:. mg/L 14. Chlorination Disinfection Byproducts (551) (1^C/MS Semivolatile Unknown Scan
Total Chlorine Res: mg/L 15. Haioacetic Acids (552) IS; Purgeable Halocatbona (DEF)
16. Pesticides (SM18/6630) 16. Purgeable Aromatics (DEF)
pH 17. Petroleum/Hydrocarbon Scan (310-13) 17. PestIcldos/PCB's (DEF)
18. Other__________ _ __________ _ 18. Other. 1
INORGANIC ANALYSIS REQUESTED - Lab#:
(circle tests)
1. Color 20. Acidity 39. Aluminum 59. Potassium
2. Turbidity 21. Alkalinity, as CaCOs 40. Antimony 60. Selenium
3. pH 22. Bromide 41. Arsenic 61. Silver >
4. Conductivity 23. Bromate/Chlorate/Chlorite 42. Barium 62. Sodium
5. Corrosivity (temp;®C) - 24. Chloride 43. Beryllium 63. Thallium
6. BOD (5 day) 25. Cyanide 44. Boron 64. Vanadium
7. Soluble BOD (5 day) 26. Fluoride 45. Cadmium 65. Zinc
8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOs 46. Calcium, as CaCOs ^LP
9. Chemical Oxygen Demand 28. Nitrogen, Ammonia as N 47. Calcium, Ca*® 66.Metal8/CN
10. Dissolved Ot^en 29. Nitrogen, Nitrate as N 48. 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 50.Cobalt 69.Pesticides/PCB's
13. Solids, Percent (%) 32. Oil an Grease 51. Copper 70. Disk Deliverables
14. Solids, Settleable 33. Phenol 52. Iron
15. Solids, Suspended 34. Phosphorus Total as P 53 .Lead ICLE
71 .TCLP-Metals
16. Solids, Total 35. Phosphorus, Ortho as P 54 Magnesium
72.TCLP-Posticldos
17. Solids, Total Dissolved 36. Sulfates 55 Manganese 73.TCLP-Herblcides
18. Solids, Total Volatile 37. Surfactants 58. Mercury
74. TCLP-Volatiles
19. Other:________________ 38.UV254 67 Molybdenym
76.TCLP-BNA'8
68. Nickel .
NYC-WTC_000070410
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