NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
UtejUHLty WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
(914) 593-5575 NYS-ELAP No. .10108
Time/Date Set: __________________________ Form A-70 (rev. 1/96)
SaroPleTyjpe (circle one):
'l, Potabl^^ 3. Non-Potable Treated Bottle #’s:<^* ^7 <3^
(
■Y'TIorbPS^Ie 4. Other __________ Chain of Custody? Y®s .no
Time/Date'Collected: fl ' 6gAw II 1^0 > Comments:
Collected By: . Aoenev Code:. PWS#;________ .Source ID:. .Type Descriptor.
Collected From: Bill to:
Location’s/lndivldual’s Name_ Name/Company
Street ______________ Street_________
Oity/St/Zp,^________ _ City/St/Zip_____ _
Identification of Source. Phone»:_ Fax#:.
Collection Point I CA. CH. Bl? Check#: Amounts.
BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLIDANALYSES
Lab#-:La_ai^Si>- Lab#:
; (circletests) .. (circle tests) .. .
: 1, Hpterdtrophic Plate y" Y 1. Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260pfc
count (hemodfa!ysis' & all'others) 2. Purgeable Aromatics (624i?^) ^?W >
2. Coliform P/A public supplies) ■3/ vuraina’ATOi'fuiiLj (sp <) 3. Acrolein & Acrylonitrile (624) ;
3. Coliform MPN (priv well, raw. stp) 4. Total Trihalomethahe Potential (510) 4. Phthalates (606/8060)
4. Fecal Coliform (ail samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8080) -
5. Microscopic 6. Pesticides (507) '6. PCB’s (Arochlors) (608/8080)
6. Macroscopic ^Pesfaidois/PODTOToun (GOS) 7. Herbicides (SM-18/6640; 8151)
8. PCB as Decachlorobiphenyl (508A) 8. Other Pesticides (SM-18/6630)
8. Oler: a Herbicides (515) 9. Petroleum Hydrocarbon Scan (310-13)
@ ProtiLidos (OPC) 10. Glycols in Water
RefriSrated? yes •- no . n. Carbamate Pesticides (531) 11. Acid Ext/actables (625/8270)
12. Glyphosate (547) ^.^ase Neutral Extractables (625/8270).
OhlonnWd?: \ ves no ; 13. Diquat (549) ^sJgC/MS Unknown Scan
14. Chlorination Disinfection Byproducts (551) 14 Purgeable Halocarbons (DEF)
Free Chlonne Res:, .fng/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)
I?.
pH SSB
INORGANIC ANALYSES REQUESTED &ab#:.
pl, ta
(circle tests) ■
1. Color ^^»^luminum 59. Potassium
2. Turbidity . 2K/^alinity, as CaCOs 140. Antimony r^OjSelenium
3- pH . ■ Brnmido 141. Arsenic Wsilver
4. Conductivity SS. B^mate/Chlorate/Chlorito l42. Barium 62. Sodium
5. Corrosivity (temp: ’C) 2>CJj|pride ^)<g^eryllium '63?;Thallium
6. BOD (5 day) 25. Cyanide 44. Boron §4. 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 CaCOs ctE
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 Jg. Chromium, Hexavalent 68. Semi-volatiles
12. Total Oi lie Halides 31. Nitrogen, Total Kjeldahl as N /goXobalt 69. Pesticides/PCB’s
13. Solids, I (%) 32. Oil and Grease 151. Copper 70. Disk Deliverables
14. Solids. J Ie 33, Phenol j 52. Iron ISLE
15. Solids, Si inded 34, Phosphorus. Total as P <5^ead 71. TCLP-Metals
16. Solids. T( ®iosphorus. Ortho as P Magnesium 72. TCLP-Pesticidos
17. Solids. T Dissd|e^ ' ' gl^imtfates ^^Manganese 73. TCLP-Herbicides
l^Solids. Total Vol^ '37. Surfactants 56.|Mercury 74. TCLP-Volatiles
b^lV254 |57.iMolybdenum 75. TCLP-BNA's
^8/Nickel
NYC-WTC_00b07078f''
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