NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
111
Utertchortor County
Time/Date Set:__________
WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
(914) 593-5575 NYS-ELAP No. 10108
Form A-70 (rev. 1/96)
Sample Type (circle one):
3. Non-Potable Treated Bottle Vs:
1. Potable
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. I Name/Company
Street____________________ Street___________
City/St/Zip________________ City/St/Zip
Identification of Source Phone#: Fax #:
I CA, CH, Bl? Check#;_. Amounts.
Collection Point. '
BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES
Lab#:_________________________ Lab #:__________________ _____________
(circle tests) (Circle tests)
1. Heterotrophic Plate 1..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 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 Pesticides (507) 6. PCB’s (Arochlors) (608/8080)
6. Macroscopic Pesticides/PCB screen (508) 7. Herbicides (SM-18/6640; 8151)
7, AP; 8. PCB as Decachlorobiphenyl (508A) 8. Other Pesticides (SM-18/6630)
8. Other:_____________________ 9. Herbicides (515) 9. Petroleum Hydrocarbon Scan (310-13)
fj,(LPesticides (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) (l,3\ 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)
pH
A
INORGANIC ANALYSES REQUESTED - Lab#;
(circle tests)
,• 3^. Aluminum
1. Color 20. Acidity 59. Potassium
2. Turbidity 21. Alkalinity, as CaCOs I 40.^ Antimony . 60, Selenium ; / ' y
3. pH 22. Bromide ; 41.i Arsenic ■ 6T. Silver
4. Conductivity 23. Brbmate/Chlorate/Chlorite ( 42j Barium 62. Sodium
5. Corrosivity (temp: .°C) 24. Chloride \ 43; Beryllium , eij'Thallium
6. BOD (5 day) 25. Cyanide '44. Boron 64. Vanadium
7. Soluble BOD (5 day) 26. Fluoride 45. Cadmium 6^: Zinc
8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOa 46. Calcium, as CaCOs CLP
9. Chemical Oxygen Demand 28. Nitrogen, Ammonia as N 4,7. Calcium, Ca*^ 66. Metals/CN
10. Dissolved Oxygen 29. Nitrogen, Nitrate as N • 48. 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 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 Dissolved 36. Sulfates 5^. Manganese 73. TCLP-Herbicides
18 Solids. Total Volatile 37 Surfactants 56. Mercury 74. TCLP-Volatiles
19. Other: . 38. I. IV254 57. Molybdenum 75. TCLP-BNA’s
58. Nickel
NYC-WTC_000071051
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