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
1..V* (914) 593-5575 NYS-ELAP No. 10108
Time/Date Set:_____ ______ Form A-70 (rev. 1/96)
Sample Type (circle one): V *5 S S,
' 1. Potable ) 3. Non-Potable Treated Bottle #’s:. k- .VH
'2?TjorbT’otable 4. Other____j_____
V 3.C7
Chain of Custody? .yes .no
Time/Date Collected:__l_’_l-i2J_i-ll^___ i__ ) I’ Comments:
Collected By:__ i ■■
Agency Code: PWS #:_________ .Source ID:. Type Descriptor..
Collected From: Bill to:
I* .. ' ' IV-'J
Location's/lndividual’s Name. Name/Company
Street__________________ Street__________
City/SVZip______________ City/St/Zip
Identification of Source Phone#: Fax #:
Collection Point*": O C? I CA, CH, Bl? Check#: Amounts
BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLIO ANALYSES
Lab#:____________________ __ Lab #:___________________________
(circle tests) (circle tests)
1. Heterotrophic Plate 1. 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 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. Olher:____j_____________ 9.-Herbicides (515) 9. Petroleum Hydrocarbon Scan (310-13) ;'
(^Pesticides (525) 10. Glycols in Water
Refrigerated? yds. 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) ^J3C/MS Unknown Scan
14. Chlorination Disinfection Byproducts (551) 14. Purgeable Halocarbons (DEF)
Free (Jbtofih^es:. mg/L 15. Haloacetic Acids (552) 15. Purgeable Aromatics (DEF)
16. Other Pesticides (SM-18/6630) 16. Pesticides (DEF)
(^otal 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
5PS?
39. Aluminum 59. Potassium .
2. T urbidity 21. Alkalinity, as CaCOa 40. Antimony 60. Selenium :
3. pH 22. Bromide 41. Arsenic 61. Silver I, CO
4. Conductivity 23. Bromate/Chlorate/Chlorite 42. Barium 62. Sodium ' I
5. Corrosivity (temp: .°C) 24. Chloride 43. Beryllium 63. Thallium j
6. BOD (5 day) 25. Cyanide 44. Boron 64. Vanadium |
7. Soluble BOD (5 day) 26. Fluoride 45. Cadmium 65. Zinc_____ L_
8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOs 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, Nitrile 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, Settleabie 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:____ ________ 38.1.IV254 57. Molybdenum 75. TCLP-BNA’s
58. Nickel
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NYC-WTC_000071191
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