NYC 9/11 Public Portal Document
UI
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
Ulectchester County (914) 593-5575 NYS-ELAP No. 10108
jP P /<; 1 V FormA-70 (rev, 1/96)
Time/Date Set:_________
Sample Type (circle one):
1.- Potable 3. Non-Potable Treated
2. Non-Potable 4. Othor/z_________ , Chain of Custody? .yes
Time/Date Collected:. Comments:
Collected Bv: Agency Code: PWS #:_________ Source ID: Type Descriptor:.
Collected From: BUI to:
Location’s/lndividual's Name 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/SOLIO ANALYSES
Lab#:__________ . ______ Lab #:____________________________
(circle tests) (circle tests)
1. Heterotrophic Plate 1. Trihaiomethanes (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. API 8. PCB as Decachlorobiphenyl (508A) 8. Other Pesticides (SM-18/6630)
8. Other:_______ ' ______ a 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) . 1Z 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 Chlorin^Res: mg/L 15. Haloacetic Acids (552) 15. Purgeable Aromatics (DEF)
16. Other Pesticides (SM-18/6630) 16. Pesticides (DEF)
Total Chlorine Ros: 17. Petroleum/Hydrocarbon Scan (310-13) ; 17. PCB's (Arochlors) (DEF)
pH
INORGANIC ANALYSES REQUESTED - Lab#: ) ft Hi 4^—1^
(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)
7. Soluble BOD (5 day)
25. Cyanide
26. Fluoride
44. Boron
45. Cadmium
64. Vanadium
65. Zinc 6\
8. Carbonaceous BOD (5 day) 27. Hardness. Total as CaCOa 46. Calcium, as CaCOs 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
13. Solids, Percent (%) 32. Oil and Grease 51. Copper 70. Disk Deliverables
14. Solids, Settleable 33. Phenol 52. Iron ISLE
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. I.IV254 57. Molybdenum 75. TCLP-BNA's
58. Nickel
NYC-WTC_000071190
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