NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
tester
govcom WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
(914)593-5575
■ NYS-ELAP No. 10108
Time/Date Set: Form A-70 (rev. 1/96)
Sample Type (circle one):
ijpotable 3. Non Potable Treated Bottle#’s: , C ^2?-_____________
2. Non Potable 4. Other Chain of Custody?___ yes___ no
Time/Date Collected: '•* \ - Comments:__________________
Collected By: "X > R < A Agency Code: PWS #:______ Source ID: Type Descriptor:
Collected From: Bill to:
Location’s/lndividual’s Name 3* Name/Company
Street_________________ Street________
City/St/Zip______________ City/St/Zip
Identification of Source Phone#: Fax#:
Collection Point 3
I C.A.CH, Bl? Check#: Amounts.
BACTERIOLOGICAL ANALYSIS ORGANIC POTA^AjaALYSI^ ORGANIC NONPOTABLE/SOUD ANALYSIS
Lab#:_______________________ (circle teste) y / f
(circle tests)
1. Heterotrophic Plate 1. Trihalometharl^^(524)
1. Purgeable Halocarbons (624/8260)
Count (hemodialysis & all others) 2. Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260)
2. Coliform P/A (public supplies) 3. Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624)
3. Coliform MPN (priv well, raw, stp) 4. Total Trihalomethane Potential (510) 4. Phthalates (625/8270)
4. Fecal Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8081)
5. Microscopic 6. Pesticides (507) 6. PCB’s (Arochlors) (608/8081)
6. Macroscopic Pesticides/PCB screen (508) 7. Methoprene (616)
7. API 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPAI 978/8151)
8. Other:__________________ __ 9. Herbicides (515) 9. Pesticides (SMI 8/6630)
Refrigerated?yes no 10. Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13)
11. Carbamate Pesticides (531) 11. Glycols
Chlorinated:? yes no 12. Glyphosate (547) 12. Acid Extractables (625/8270)
13. Diquat (549) 13. Base Neutral Extractables (625/8270)
Free Chlorine Res: mg/L i J-GC/MS Semivolatile Unknown Scan
14. Chlorination Disinfection Byproducts (551)
Total Chlorine Res:^ mg/L 15. Haloacetic Acids (552) 15. Purgeable Halocarbons (DEF)
16. Pesticides (SMI 8/6630) 16. Purgeable Aromatics (DEF)
pH ___________ 17. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB’s (I
18. Other;__________________________ 18.Other:n_J^
INORGANIC ANALYSIS REQUESTED - Lab#:
(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:. 5C) 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 65. Zinc
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-vioiatiles
12. Total Organic Halides 31. Nitrogen, Total Kjeldahl as N 50. Cobalt 69. Pesticides/PCB’s
13. Solids, Percent (%) 32. Oil an Grease 51. Copper 70. Disk Deliverables
14. Solids, Settleable 33. Phenol 52. Iron
15. Solids, Suspended 34. Phosphorus Total as P 53.Lead IfikE
54 Magnesium 71 TCLP-Metals
16. Solids, Total 35. Phosphorus, Ortho as P
55 Manganese 72.TCLP-Pesticides
17. Solids, Total Dissolved 36. Sulfates
56. Mercury 73.TCLP-Herbicides
18. Solids, Total Volatile 37. Surfactants
74. TCLP-Volatiles
19. Other:_________________ 38. UV254 57 Molybdenum
75.TCLP-BNA'S
58. Nickel
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NYC-WTC_000071430
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