NYC 9/11 Public Portal Document
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UtMichMtBr County
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road. Valhalla, New York 10595
(914) 593-5575
SI
NYS-ELAP No. 10108
J^^/Date_SeL______________________________ —LXL-L Form A-70 (rev. 1/96)
Sample Type (circle one):
l'^ Potable 3. Non-Potable Treated Bottle y: -
' 4? -
2. Non-Potable 4. Other__________________ Chain of Custody?yes .no
Time/Date Collected:_____ / < '' __ A,. Comments:
Collected By: ' ■ a - /A '' '••• ’’Agency Code:
PWS #:_______ Source ID;. .Type Descriptor:.
Collected From; Bill to:
Location’s/lndividual’s Name 'h ;
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#;________^ _______ Lab #:_________________ ■
(drcle tests) (drcle tests)
1. Heterotrophic Plate 1. Trihalomethanes (524) 1, Purgeable Halocarbons (624/8260)
Count (hemodialysis & all others) Volatile Halocarbons (524) . 2. Purgeable Aromatics (624/5260)
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)
6. Macroscopic Pesticides/PCB screen (508) 7. Herbicides (SM-18/6640; 8151)
y.,: - 8. PCB as Decachlorobiphenyl (508A)
9^ Herbicides (515)
Pesticides (525)
8. OtherPesticides (SM-18/6630)
9. Petroleum Hydrocarbon Scan (310-13)
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) ^^C/MS Unknown Scan
14. Chlorination Disinfection Byproducts (551) T?; 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)
/ r- --7
INORGANIC ANALYSES REQUESTED - Lab#;.
(circle tests)
1. Color 20. Acidity 39. Aluminum 59. Potassium
2. Turbidity 21. Alkalinity, as CaCOa 40. Antimony 60. Selenium
3. pH 22. Bromide 41. Arsenic 61. Silver
4. Conductivity 23. Bromate/Chlorate/Chlorite 42. Barium 62. Sodium
5, Corrosivity (temp: .’C) 24. Chloride 43. Beryllium 63. Thallium
6. BOD (5 day) 25. 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 CaCOj 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 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
^^olids. Percent (%) 32. Oil and Grease 51. Copper 70. Disk Deliverables
^Bolids. Settleable 33. Phenol 52. Iron tclp
l^^olids. 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 55. 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_000071095
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