NYC 9/11 Public Portal Document
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Time/Date Set: /'
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
WESTCHESTER COUNTY LABORATORIES AND
2 Dana Road, Valhalla, New York 1^9^
,rai4) 5^3-5575
ARCH
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NYS-ELAP No. 10108
Form A-70 (rev. 1/96)
Sample Type ^(circle one): r 063^
1. Potable 9 3. Non-Potable Treated Bottle
2. Non-Potable 4. Other_____________ _ Chain of Custody? .yes_____ no
Time/Date Collected:. _ Comments: __4----------------
Collected By: .Yj Agency Code:, _ PWS #;________ .Source tD;. .Type Descriptor:.
Collected From: Bill to:
Location’s/lndividual's Name O ft VX _ Namo/Cpmpany
\
Street______________ _ __________________ — ' "Street J
City/St/Zip________________ ;______________ _ Citv/St/Z^
Identification of Source _,Phone#:J"'Y- ..Fax #:,
g | CA,CH, Bl?. Check#: Amounts.
Collection Point
BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES
Lab#:_______________ ■' Lab
(circle tests) (drctelest^ ? [Y • Y/ .
1. Heterotrophic Plate 1. Trihalomethanes (524) ; ' ' i - - 1. Purgeable Halocarbons (624/8260) : ;
Count (hemodialysis & all others) Volatile Halocarboris (524) '' 2. Purgeabie Aromatics (624/8260) >
2. Coliform P/A (public supplies) j/ Volatile Arpniatics (524) . /•/: 3." At^l^Trt & A^lonitrilo (624)
3. Coliform MPN (priv well, raw. stp) 4. Total Trihalomethane Potential (510) 4. Phthalates (606/8060)
4. Fecal Coliform (all samples) 5. Microextractables (504) 5. OrgariochlOrine Pesticides (608/8080)
5. Microscopic 6. Pesticides (507) 6. PCB’s (Arochlors) (608/8080)
6. Macroscopic Pesticides/PCB screen (508) j 7. Herbicides (SM-18/6640;.8151) ,
7. API PCB as Decachlorobiphenyl (508Aj \ 8. Other Pesticides (SM--16/^^) "
8. Other:___________________ Herbicides (515) 9. Petroleum Hydrocarbon Sdan (310-13)
Qy. Pesticides (525) 10. Glycols in Water
Refrigerated? yes,no m. Carbamate Pesticides (531) 11. Acid Extractables (625/8270)
12. Gly'phosate (547) ^Base Neutral Extractables (625/8270) ".f?
Chlorinated?: yes no 13. Diquat (549) ^^GC/MS Unknown Scan
14. Chlorination Disinfection Byproducts (551) t2k Purgeable Halocarbons (DEF)
Free Chlorine Res:. .mg/L 15. Haloacetic Acids (552) 15. Purgeable Aromatics (DEF)
16. Other Pesticides (SM-18/6630) 16. Pesticides (DEF)
Total Chlorine Res: mg/L 17. Petroleum/Hydrocarbon Scan (310-13) 17. PCB’s (Arochlors) (DEF)
pH
i
INORGANIC ANALYSES REQUESTED - Lab#:
(circle tests)
1. Color 20. Acidity 39. Aluminum 59. Potassium
2. Turbidity 21. Alkalinity, as CaCOa^ 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 CaCOa 46. Calcium, as CaCOa CLE
9. Chemical Oxygen Demand 28. Nitrogen, Ammonia as N 47. Calcium, Ca*^ 66. Metals/CN
10. Dissolved Oxygen 29. Nitrogen, Nitrate as N 48. Chromium, Total 67. Volatiles
11. Total Organic Carbon 30. Nitrogen^ Nitrite as N 49. Chromium, Hexavalent 68, Semi-volatiles
12. Total. Organic Halides 31. Nitrogen, Total Kjeldahl as N 50. Cobalt 69. Pesticides/PCB's
13. Solids, Percent (%) 32. Oil and Grease 51. Copper 70. Disk Deliverables
14. Solids. Settleable 33. Phenol 52. Iron ISLE
15. Solids. Suspended 34. Phosphorus, Total^ P 53. Lead 71.TCLP-Metals
16. Solids. Total 35. Phosphorus, Ortho as P 54. Magnesium 72. TCLP-Pesticides
17. Solids. Total Dissolved 36. Sulfates 55. Manganese 73. TCLP-Herbicides
18. Solids. Total Volatile 37. Surfactants 56. Mercury 74. TCLP-Volatiles
19. Other:_____________ 38. IIV254 57. Molybdenum 75. TCLP-BNA’s
58. Nickel
NYC-WTC_OOo67O573
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