NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
HI
UadehMlar County
Time/Date Set:
WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
(914) 593-5575
_______________________ _ __________ f'
NYS-ELAP No. 10108
Form A-70 (rev. 1/96)
pie Type (circle one): O' ‘
otable 3. Non-Potable Treated #.s: _____________
2. Non-Potable 4. Other_____________ Chain of Custody? .yes no
Time/Date Collected:. : n|i)pi__________ OlO Comments:
Collected By: > .•■yf. zc Agency Code: PWS #:_________ Source ID:. Type Descriptor:.
Collected From: Bill to;
Location’s/lndividual’s Name. Name/Company
Street______ :___________ Street__________
City/St/Zip_______________ 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 lesls)
1. Heterotrophic Plate t. 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 CoWorm (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)
7.AP! 8. PCB as Decachlorobiphenyl (508A) 8. Other Pesticides (SM-18/6630)
8. Other: 9. Herbicides (515) 9. Petroleum Hydrocarbon Scan (310-13)
(^Pesticides (525) 10. Glycols in Water
Refrigerated? yes ■ no tr Carbamate Pesticides (531) 11. Acid Extractables (625/8270)
12. Glyphosate (547) 12„^ase Neutral Extractables (625/8270)
Chlorinated?: ves no 13. Diquat (549) ^^|3C/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) '■54 16. Pesticides (DEF)
Total Chlorine Res: mg/L 17. Petroleum/Hydrocarbon Scan (310-13) .,17. PCB’s (Arochlors) (DEF)
INORGANIC ANALYSES REQUESTED - Lab#;.
(circle tests)
1. Color 20. Acidity 39. Aluminum 59. Potassium
2. Turbidity 21. Alkalinity, as CaCOa 40. Antimony- 60. Seleniurrt
3. pH 22. Bromide 41. Arsenic 61. Silver I
4. Conductivity 23. Bromate/Chlorate/Chlorite 42. Barium 62. Sodium j
5. Corrosivity (temp; •C) 24. Chloride 43. Beryllium 63. Thalliumf
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 CaCOs CL£
9. Chemical Oxy^n 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 I£L£
15. Solids, Suspended 34. Phosphorus. Total as P 53. Lead 71. TCLP-Melals
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. '.IV254 57. Molybdenum 75. TCLP-BNA’s
58. Nickel .
‘NYC-WTC_OOOO71188
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