NYC 9/11 Public Portal Document
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ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
Utadchecter County (914)593-5575 . , NYS-ELAP No. 10108
Time/Date Set:________ _____________________________
_______________ ■ *v /■ > ' f - ' Form A-70 (rev. 1/96)
^jj^mple Type (circle one): . S- ■' '-i Li I '6
1. Notable 3. Non-Potable Treated Bottle y A / 1 V V X.
'^Non-Potable 4. Other,____---------------------------------- yes no
Chain of Custody?
.Time/Date Onllente^ — Comments:
Collected Ry: Agency Code: PWS #:_________ Source ID: Type Descriptor:,
Collected From: i i t 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#: Amounts
BACTERIOLOGICAL ANALYSES « ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES
Lab#:_________ _ _________ _ Lab #:_________________ ______
(circle tests) {circle lests)
1. Heterotrophic Plate , , 1. Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260)
Count (hemodialysis. & all others)
2. Coliform P/A (public supplies)
3. Coliform MPN (priy .well, raw, stp)
© Volatile Halocarbons (524)
Volatile Aromatics (524)
4. Total Trihalomethane Potential (510)
2. Purgeable Aromatics (624/8260)
3. Acrolein & Acrylonitrile (624)
4. Phthalates (606/8060)
4; Fecal Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8080)
Pesticides (507) 6. PCB’s (Arochlors) (608/8080)
5. Microscopic
6. Macroscopic
7. AP! 5.
6 Pesticides/PCB screen (508)
8. PCB as Decachlorobiphenyl (508A)
7. Herbicides (SM-18/6640; 8151)
8. Other Pesticides (SM-18/6630)
8, Other:_______________ ^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) IX 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.„Haloacetiq Acids (552) 15. Purgeable Atomatics (DEF)
16. Other Pesticides (SM-1^6630). 16. Pesticides (DEF|
Total Chlorine Res: .mg/Lz 17. Petroleum/Hydrocarbon Scan (310-13) 17. PCB's (Arochlors) (DEF)
Pkt . O t;/-- ----
INORGANIC ANALYSES REQUESTED - Lab#:
(circle tests)
1. Color 20. Acidity 39. Aluminum 59. Potassium
2. T urbtdity 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 . I
7. Soluble BOD (5 day) ' 26. Fluoride 45. Cadmium 65. Zinc
8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOa 46. Calcium, as CaCOs CL£
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
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 55. Manganese 73. TCLP-Herbicides
18. Solids. Total Volatile 37. Surfactants 56. Mercury 74. TCLP-Volatiles
19. Other: _ ___________ 38. IIV254 57. Molybdenum 75. TCLP-BNA’s
58. Nickel
NYC-WTC_000071186
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