NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
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Time/Date Set:
WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
(914)593-5575 NYS-ELAP No. 10108.
Form A-70 (rev. 1/96)
C CMRT
Sample'Type (circle one):
Bottle #'s^' ST4
fl. Potable^ 3. Non-Potable Treated
2? NoTi-Potable 4. Other________ Chain of Custody? .yes no
Time/Date Collected: Comments:
Collected By: 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 #:,
TV
Collection Point ■
I CA, CH, Bl? Check#: Amounts,
BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES
Lab#:______________ Lab #:■ ____________ :
(circle tests) (circle tests)
1. Heterotrophic Plate Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260)
Count (hemodialysis & all others) -*2A Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260) '
2. Coliform P/A (public supplies) J 3j/Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624)
3. Coliform MPN (priv well, raw, stp) Total Trihalomethane Potential (510) 4, Phthalates (606/8060) , \
4. Fecal Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8080)
5. Microscopic z&s 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:___________________
Refrigerated? yes no
a Herbicides (515)
I. Pesticides (525)
11. Carbamate Pesticides (531)
12. Glyphosate (547)
9. Petroleum Hydrocarbon Scan (310-13)
10. Glycols in Water
11. Acid Extractables (625/8270)
12. Base Neutral Extractables (625/8270) .
Chlorinated?: .yes no 13. Diquat (549) QxGC/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: .mg/L'- 17. Petroleum/Hydrocarbon Scan (310-13) 17. PCB's (Arochlors) (DEF)
f A
'StT------
INORGANIC ANALYSES REQUESTEDj tab#.
f
'-;fs
(circle tests) ' '
1. Color Afcidity 39. Aluminum 59. Potassiufn
2. Turbidify 21. Alkalinity, as CaCOs 40. Antimony 60. Seleniur^
3. pH bromide 41. Arsenic 61. Silver ’
4. Conductivity 23. Btomate/Chlorate/Chlorrte 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 eSZinc___________
8. Carbonaceous BOD (5 day) 27. Hardness. Total as CaCOs 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 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. UV254 57. Molybdenum 75. TCLP-BNA’s
58. Nickel
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NYC-WTC_000071272
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