NYC 9/11 Public Portal Document
UI
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
UlestchMter County NYS-ELAP No. 10108
(914) 593-5575
Time/Date Set:________________________ c- - 07 ir Form A-70 (rev. 1/96)
Sample Type (circle one):
7 Potable 3. Non-Potable Treated Bottle #V: ~ H "7-7
2. Non-Potable 4. Other Chain of Custody? .yes no
Time/Date Collected: ' ' Comments;
Collected By: Agency Code: PWS #:_________ Source ID: Type Descriptor:,
Collected From; Bill to.
Location's/lndividual’s Name Name/Company
Street___________________ Street___________
City/SVZip_______________ City/St/Zip
Identification of Source Phone#: Fax #;.
Collection Point, rCA?CH~Bi?^^ Check#: Amounts.
BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES
Lab#;______________________ Lab #:
(circle tests) (circle lests) ' O 3 /
1. Heterotrophic Plate 1. Trihalomemanes (524) 1. Purgeable Halocarbons (624/8260)
Count (hemodialysis & all others) (Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260)
2. Coliform P/A (public supplies) ' Volatile Aromatics (524) 3.' Acrolein & Acrylonitrile (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. Organochlorine Pesticides (608/8080).
5. Microscopic .6. Pesticides (507) 6. PCB’s (Arochlors) (608/8080) I
6. Macroscopic ^-^Pesticides/PCB screen (508) 7. Herbicides (SM-18/6640; 8151) a -
7. API 8; PCB as Decachlorobiphenyl (508A) 8. , Other Pesticide8 (SM-18/6630)
8. Other:___________________ ^Herbicides (515) 9. Petroleum Hydrocarbon Scan (310-13)
^^^cides (525) 10. Glycols in Water .
Refrigerated? J yes no TLCarbamate Pesticides (531) 11. Acid'Extractables (625/8270)
12. Glyphosate (547) I^Base Neutral Extractables (625/8270}
Chlorinated?: .yes no 13. Diquat (549) ^WGC/MS Unknovvn Scan
14. Chlorination Disinfection Byproducts (551) TA. Purgeable Halocarbons (DEF)
Free Chlorine Res:. mg/L 15. Haloacetic Acids (552) 15. Purgeable Aromatics (DEF) 4;'
16. Other Pesticides (SM-18/6630) ■ J 6. Pesticides (DEF)
Total Chlorine Res; mg/L 17. Petroleum/Hydrcxjarbori Scan (310-13) 17. PCB's (Arochlors) (DEF) ,
pH
INORGANIC ANALYSES REQUESTED - Lab#;
'(circle tests) ' I •..•.J
1. Color 20. Acidity 3^ Aluminum 59. Potassium CIS
2. Turbidity 21. Alkalinity, as CaCOa 40.tAntimony /'ecO^elenium
3. pH 22. Bromide 41.|Arsenic (^^_6pGilver
4. Conductivity 23. Bromate/Chlorate/Chlorite 42.fearium' 62. Sodiur t I
5. Corrosivity (temp: .°C)I 24. Chloride 43r Beryllium Thallium
6. BOD (5 day) 25. Cyanide 44. Boron Vanadium
7. Soluble BOD (5 day) 26. Fluoride 45. Cadmium Zinc ,7
8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOs 46. Calcium, as CaCOa CLE? r
9. Chemical Oxygen Demand 28. Nitrogen, Ammonia as N ^7. 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 49. Chromium, Hexavalent 68. Semi-volatiles
12. Total Organic Halides 31. Nitrogen, Total Kjeldahl as N Cobalt 69. Pesticides/PCB's
13. Solids, Percent (%) * 32. Oil and Grease Copper 70. Disk Deliverables
14. Solids, Settleable 33. Phenol Iron TCLP
15. Solids. Suspended 34. Phosphorus. Total as P Lead 71. TCLP-Metals
16. Solids, Total 35. Phosphorus, Ortho as P 54. Magnesium 72. TCLP-Pesticides
17. Solids, Total Dissolved 36. Sulfates /'55)^angane6e 73. TCLP-Herbicides
Solids. Total Volatile 37. Surfactants / 56. Mercury 74. TCLP'-Volatiles
■■ 19. Other; ri 38. IIV254 I 57. Molybdenum 75. TCLP-BNA's
i 58>4jickel
NYC-WTC_000070909
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