NYC 9/11 Public Portal Document
UI
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
UJMtehMtar County
(914) 593-5575 NYS-ELAP No. 10108
Time/Date Set:_________ Form A-70 (rev. 1/96)
Sample Type (circle one):
(J^Potable 3. Non-Potable Treated Bottle #’^' F 0 I 6-7 1
2. Non-Potable 4. Other __________________________ Chain of Custody? .yes .no
Time/Date Collected:Z/ - J f ? Comments;
Collected By: “7 Code: PWS #:_________ Source ID;. Type Descriptor:.
Collected From: Bill to.
Location’s/lndividual’s Name F7<J
Name/Company
Street____________________ _______________ "" * _____ Street__________
City/SVZip_________ _____________ __ __________________ City/St/Zip
Identification of Source_____________________________ _____ Phone#: Fax #:
Collection Point, I CA. CH, Bl? Check#: Amounts.
BACTERIOLOGICAL ANALYSES . ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES
Lab#:_____A_l_:__^l.:_ . . • '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 Arorinatics (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)
6. Macroscopic Pesticides/PCB screen (508) 7. Herbicides (SM-18/6640; 8151)
7. API 8. PCB as Decachlorobiphenyl (508A) 8. Other Pesticides (SM-18/6630)
j;
8. Other:___________________ 9. 'Herbicides (515) 9. Petroleum Hydrocarbon Scan (310-13)
QO^esticides (525) 10. Glycols in Water
Refrigerated? .yes. .00 ■; i lT Carbarhate Pesticides (531) 11. Acid Extractables (625/8270)
12. Glyphosate (547) 1J2^Base Neutral Extractables (625/8270)
Chlorinated?: .yes. .no. .r 13. Diquat (549) . ^J^C/MS Unknown Scan
I.
14; Chlorination Disinfection Byproducts (551) 14. 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)
pH.
INORGANIC ANALYSES REQUE^^
(circle tests)
f
1. Color Muminum 59, Potassiurn
2. Turbidity ■ pSAIkalinity, as CaCOs 40. Antimony /So^elenium'
3. pH ^i^^rqmide 41. ^rsenic Silver j
4. Conductivity ■'^3;^ r^ate/Ch lorate/Ch lorite 42.fearium 62. Sodium i I
5. Corrosivity (temp; .“C) ■’^iCh^'ride ^^Beryllium ■^63pThallium
6. BOD (5 day) Boron M. Vanadium
7. Soluble BOD (5 day) 45. Cadmium (1S5>inc
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 /^S^hromium. Total 67. Volatiles
11. Total Organic Carbon 30. Nitrogen. Nitrite as N 4^ Chromium. Hexavalent 68. Semi-volatiles
12. Total Organic Halides 31. Nitrogen. Total Kjeldahl as N /SO^obaft 69. Pesticides/PCB’s
13. Solids, Percent (%) 32. Oil and Grease I 51. Copper 70. Disk Deliverables
14. Solids, Settleable 33. Phenol I 52. Iron TCLP
15. Solids, Suspended 34. Phosphorus. Total as P I 53Xead 71. TCLP-Metals
16. Solids, Total 35. Phosphorus, Ortho as P 53^ 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
1^ Other: \ (A________ 38. IIV254 57. Molybdenum 75. TCLP-BNA’s
SS/Nickel
NYC-WTC_000070988
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