NYC 9/11 Public Portal Document
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ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
WESTCHESTER COUNTY LABORATORIES ANO RESEARCH
2 Dana Road. Valhalla, New York 10595
UlMtchMW County NYS-ELAP No. 10108
(914) 593-5575
Time/Date Set:_________________________ Form A-70 (rev, 1/96)
Sample Type (circle one):
1. Potable 3. Non-Potable Treated Bottle #'s:.
2. Non-Potable 4. Other Chain of Custody? yes no
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Time/Date Collected:____________________ Comments:
Collected By: I Agency Code: PWS #:____________ Source ID: Type Descriptor:.
Collected From: Bill to:
Location’s/lndividual’s Name. 1 <} <1 ^71 /"j n tC Name/Company
Street_______ :__________ Street
City/St/Zip_______________ City/St/Zip__________
!■ I—I
Identification of Source Phone#:____________ Fax #:
Collection Point : FPj I CA. CH. Bl? Check#: Amounts
BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLIO ANALYSES
Lab#: ' ' Lab •#: ...
(circle tests) . ' ’ " (circle tests) . ,
1. Heterotrophic Plate . ' 1. Trihalomethanes (524) , . ' 1. Purgeable Halocarbons (624/8260)
Count (hemodialysis & all others) 2. Volatile Halocarbons (524) * . ■ 2. Purgeable Aromatics (624/8260)
2. Coliform P/A '(public supplies) 3. Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624)
3. Coliform MPN (prlVswell, raw, stp) 4. Total Trihalomethane Potential (510) 4., Phthalates (606/8060)
4. Fecal Coliform (all sainples) 5. Microextractablos (504) 5. Organochlorine Pesticides (608/8080) >
5, Microscopic 6. Pesticides (507) 6. PCB's (Arochlors) (608/8080)
6. Macroscopic 7. Pesticides/PCB screen (508) 7. Herbicides (SM-18/6640; 8151)
7. API 8. PCB as Decachlorobiphenyl (508A) 8. Other Pesticides (SM-18/6630) ;.
8. Other: d 9. Herbicides (515) 9. Petroleum Hydrocarbon Scan (310-13)
10. Pesticides (525) 10. Glycols in Water
Refrigerated? .yes. no 11. Carbamate Pesticides (531) 11. Acid Extractables (625/8270)
12. Glyphosate (547) 12. Base Neutral Extractables (625/8270)
Chionnated?: yes .no 13. Diquat (549) A 3?GC/MS' Unknown Scan
14. Chlorination Disinfection Byproducts (551) T4f 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)
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INORGANIC ANALYSES REQUESTED? Lab#:
(circle tests)
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1. Color T 20. Atidity 39. Aluminum 59. Potassium
2. Turbidity >.2.1. Alkalinity, as CaCOs 40. Antimony 60. Selenium!
3. pH " 22. Bromide 41. Arsenic 61. Silver |
4. Conductivity 2k Bromate/Chlorate/Chlorite 42. Barium 62. Sodium ■' t''"
5. Corrosivity (temp: ?C) 24. Chloride 43. Beryllium 63. Thallium
6. BOD (5 day) -^5. 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 CaCOs CLP
9. Chemical Oxygon Demand 28. Nitrogen, Ammonia as N 47. Calcium, Ca*^ 66. Metals/CN
10. Dissolved Oxygen 29. Nitrogen, Nitrate as N 48. ChromiOm, 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 TCLP
15. Solids. Suspended 34. Phosphorus. Total as P 53. Lead 71.TCLP-Metals
16. Solids. Total 35. Phosphorus, Ortho as P 54. Magnesium 72. TCLP-Pesticides
17. Solids. Total DissoNed 36. Sulfates 55. Manganese 73. TCLP-Herbicides
18. Solids, Total Volatile 37. Surfactants 56. Mercury 74. TCLP-Volatiles
19. Other: ( 38. UV254 57. Molybdenum 75. TCLP-BNA’s
58. Nickel
NYC-WTC_000070982
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