NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
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WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
(914)593-5575
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NYS-ELAP No. 10108
Form A-70 (rev. 1/96)
Time/Date Set:_________
Sample Type (circle one):
1, Potable 3. Non-Potable Treated Bottle #'s: <
2. Non-Potable 4. Other____________ Chain of Custody? yes no
Time/Date Collected:. Comments:
Collected Bv: /. V/i 1/Agency Code: PWS Source ID: Type Descriptor:
Collected From: Bill to:
Location’s/lndividual’s Name. Name/Company.
Street__________________ Street________
C ity/St/Zip_____________ L 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#:______________________ Lab #:____________________________
(circle tests) (circle tests)
1. Heterotrophic Plate l./Trihalomethanes (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 wel^, 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 <7r 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:___________________ 9,^ Herbicides (515) 9. Petroleum Hydrocarbon Scan (310-13)
. ^dr-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)
Chlorinated?: yes no 13. Diquat (549) (Tj^GC/MS Unknown Scan
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)
£!±_.
INORGANIC ANALYSES REQUESTEDp Lab#:
(circle tests) ;
1. Color 20. Acidity /^AAluminum 59. Potassium
2. Turbidity 21. Alkalinity, as CaCOa 40.jAntimony “SS^Selenium
3- pH 22. Bromide 41 .lArsenic Silver
4. Conductivity 23. Bromate/Chlorate/Chlorite . 42./Barium "52. Sodium
5 Corrosivity (temp: .°C) 24. Chloride Beryllium Thallium
6. BOD (5 day) 25. Cyanide 44. Boron Vanadium
7. Soluble BOD (5 day) 26. Fluoride 45. Cadmium rgZinc _____
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 •{48i 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 7 S^Cobalt 69. Pesticides/PCB’s
13. Solids, Percent (%) 32. Oil and Grease / 51. (Copper 70. Disk Deliverables
14. Solids, Settleable 33. Phenol 52.#ron ICLP
15 Solids, Suspended 34. Phosphorus. Total as P i S^Lead 71. TCLP-Metals
16. Solids, Total 35. Phosphorus, Ortho as P Magnesium 72. TCLP-Pesticides
17. Solids, Total Dissolved 36. Sulfates /'55\ Manganese 73. TCLP-Herbicides
^1.8 Solids. TotaLVolatile 37 Surtactants / 56.1 Mercury 74. TCLP-Volatiles
19 Other- > K 38. UV254 ( 57;Molybdenum 75. TCLP-BNA’s
I 58- Nickel
NYC-WTC_000071048
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