NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
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|^/Date_Set_________
WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road. Valhalla. New York 10595
(914)593-5575
' { -
j' NYS-ELAP No. 10108
Form A-70 (rev. 1/96)
Sample Type (circle one): , VS r V 7
,1. Potable 3. Non-Potable Treated i 5 2- - . f -I 2,'1 <<Z>
2. Non-Potable 4. Other Chain of Custody? .yes no
Time/Date Collectod:_______________ ~ I iL-iL. . Comments:
Collected Bv: / ■ ■ V- / Agency Code: PWS #:_______ Source ID:. Type Descriptor:
Collected From: Bill to:
Location's/lndividual’s Name. / / Name/Company.
Street_______ ___________ Street
City/SVZip____________ City/St/Zip
Identification Of Source:____ Phone#:_____ ■_ _Fax #:_
Collection Point. / I CA. CH. Bl? Check#: Amount^
BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES
Lab#:_______2___________ Lab #:_________ _______________ _
(circle tests) _. ' . (circle tests)
1. Heterotrophic-Plate Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260)
Count (hemodialysis. & ail others) Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260)
2. Coliform P/A (public supplies) Volatile Aromatics (524) 3. Acrolein_& Acrylonitrile (624)’
3. Coliforrp'MPN (priv well, raw, stp) 4. Total Trihalomethane Potential (510) 4. Phthalates (606/8060)
4. Fecsi Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8080)
5. Microscopic 6. Pesticides (507) 6. PCB's (Arochlors) (608/8080)
6. f^troscopic Pesticides/PCB screen (508) 7. Herbicides (SM-18/6640; 8151)
8. PCB as Decachlorobiphenyl (508A) 8. Other Pesticides (SM-18/6630)
9. Herbicides (515) 9. Petroleum Hydrocarbon Scan (310-13)
Pesticides (525) . 10. Glycols in Water
Refrigerated? yes no 11. Carbamate Pesticides (531) 11. Acid Extractables (625/8270)
12. Glyphosate (547) ^ Base Neutral Extractables (625/8270)
Chlorinated?: .yes no 13. Diquat (549) ; ^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: J__ mg/L 17. Petroleum/Hydrocarbon Scan (310-13) 17. PCB’s (Arochlors) (DEF)
pH
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 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 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 Kieldahl as N 50. Cobalt ___ 69. Pesticides/PCB's
t^^ohds. Percent (%) 32. Oil and Grease 51. Copper 70. Disk Deliverables
^Bolids, Settleable 33. Phenol 52. Iron T£L£
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_000071096
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