NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
iv.com WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
(914) 593-5575
NYS-ELAP No^ 10109
Time/Date Set: Form A-70 (rev.1/96)
Sample Type (circle one): ^7?^/ 3->/ V -
'_1.,Potable 3. Non Potable Treated Bottle #’s;
2. Non Potable 4. Other____________ Chain of Custody?___ yes no
Time/Date Collected: // Commente:
Collected By: zA/A Agency Code: PWS#:______ Source ID: .Type Descriptor
Collected From: Bill to:
Location’s/lndividuars Name Name/Company
Street_________________ Street________
City/St/Zip_______ . City/St/Zip____
Identification of Source .. ....... Phone#: Fax#:
Collection Point
FcACHTm? ■■ i;
Check#: Amounts <
bacteriological analysis ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOUD ANALYSIS
Lab#: - ' Lab#:_________
(circle tests) (cirde tests)
1. Heterotrophic Plate 1. -Tnhalomethanes (524) 1. Purgeable Halocarbons (624/8260)
Count (hemodialysis & all others) 2. Purgeable Aromatics (624/8260)
2. Coliform P/A (public supplies) -rS^SVeiatile-Aromatics-fSaA) 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) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8081)
5. Microscopic ^rPesticides (507) 6. PCB’s (Arochlors) (608/8081)
6. Macroscopic • 7,^esticides/PCB screen (508) 7. Methoprene (616)
7. API '-eTTCB as Decachlorobiphenyl (508A) 8. Herbicides (EPAI 978/8151)
8. Other____________________ /9r4(erbicides (515) 9. Pesticides (SMI8/6630)
Refrigerated?yes no
ia les (525) 10. Petroleum Hydrocarbon Scan (310-13)
TbCarbamate 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) 14. GC/MS Semivolatile Unknown Scan
Total Chlorine Res: mg/L 15. Haloacetic Acids (552) 15. Purgeable Halocarbons (DEF)
16. Pesticides (SM18/6630) 16. Purgeable Aromatics (DEF)
pH 17. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB’s (DEF)
18. Other___„__________ . 18. Other:__________________________
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 CaCOa 46. Calcium, as CaCOa CLP
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-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
34. Phosphonjs Total as P 53.Lead TCLP
15. Solids, Suspended 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. UV254 57 Molybdwum
75.TCLP-BNA'S
58. Nickel
NYC-WTC_000070655
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