NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
NYS-ELAP No.10108
Time/Date Set:_________________________ Form A-70 (rev. 1/96)
^mple Type (circle one):
Q. Potable 3. Non-Potable Treated
2. Non-Potable 4. Other _ .._K, t t _ Chain of Custody? .yes .no
Time/DateCollected^ K _ Comments:
Collected By: ♦AoencvCode: _ PWS #:_________ .Source ID:, .Type Descriptor:.
Collected From: -5 / Bill to:
Locatlon’s/lndivIduars'Name _ Name/Conpany
Street____4_______________ __ _ Street________ _
City/St/Zip \ ____________
. City/St/Zip
Identification of Source - Phone#:J -Fax#:,
Collyriion Point " Basssaua
I CA.CH Bl?. Check#: Amounts.
I BACTERIOLOGICAL ANALYSES ORGANIC POTABL| ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES
./ Lab#:_i_jiiYiH\L^&^^
■ (<*<* Y' V' ■ (eircteteste)?-/, l' Purgeable Halocarbons (624/8& ‘'
• 1; Heterotrophic Plate . ;Y 1. Trihalomethanes (524)
Count {hernod1a!ysls & all Others) W) 2. Purgeable Aromatics (624/8260) /!
2. Coliform P/A (public supplies) 3. Acrolein & Acrylonitrile (624) W
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. Organochiorine Pesticides (608/8080) -
5. Microscopic.) , Pesticides (507) ‘6. PCB’s (Arochlors) (608/8080)
6. ^crosco^V^g^^ ■ ResHeidewWB^ TtseeK 7. Herbicides (SM-18/6640; 8151) W
8. PCB as Decachlorobiphenyl (SOSA) 8. Other Pesticides (SM-18/6630) r W
.’ 8. Other: "'F-’Y/P'• Herbicides (515) 9. Petroleum Hydrocarbon Scan (310-13) . ■
Pailli&TUua'(SgD) ■■ 10. Glycols in Water
Refrigerated? yes no ‘ 11. Carbamate Pesticides (531) 11. Acid Extractables (625/8270) ;-
12. Glyphosate (547) IjL Base Neutral Extractables (625/8270)
Chlonnated?: ves no ;.13. Diquat (549) ^^GC/MS Unknown Scan
h14. Chlorination Disinfection Byproducts (551) 14. Purgeable Halocarbons (DEF)
Free Chlorine Res:. .mg/L -15. Haloacetic Acids (552) 15. Purgeable Aromatics (DEF)
’ 16. Other Pesticidos (SM-18/6630) 16. Pesticides (DEF)
Total Chlorine Res: .mg/L •^17. Petroleum/Hydrocarbon Scan (310-13) 17. PCB’s (Arochlors) (DEF)
pH
INORGANIC ANALYSES REQUESI^b liab#
(circle tests) -j .f >,
1. Color ^^Aldity
BS^AIuminum SSkPotassium
2. Turbidity 'gf; Alkalinity, as CaCOa MO.Untimony /^O.^elenium
3. pH ^^niide Ui .Arsenic \6ySilver
4. Conductivity 23; Bmmate/Chlorate/Chlorite l/^Barium Sodium
5. Corrosivity (temp: .°C) 2^, CBioride *^^eryllium ( 33: Thallium
6. BOD (5 day) •2< CYpnide 44. Boron 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
9. Chemical Oxygen Demand 28. Nitrogen, Ammonia as N Calcium, Ca*’ 66. Metals/CN
"^10. Dissolved Oxygen 29. Nitrogen, Nitrate as N US.-'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 feoi Cobalt 69. Pesticides/PCB’s
13. Solids, Percent (%) 32. Oil and Grease 51\ Copper 70. Disk Deliverables
14. Solids. Settleable 33. Phenol 524 Iron ISLE
15. Solids, Suspended 34. Phosphorus. Total as P Lead 71. TCLP-Metals
16. Solids, Total 35. Phosphorus. Ortho as P Magnesium 72. TCLP-Pesticidos
17. Solids, Total Dissolved 36. Sulfates '-nganese 73. TCLP-Herbicides
Solids. Tot^olatile 37. Surfactants ircury 74. TCLP-Volatiles
Af^ther: 38. IIV254 lolybdenum 75. TCLP-BNA’s
ickel
NYC-WTC_6oOO7O788 ........ '
OCR can misread numbers and units. Confirm readings against the page image before using them.