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
UJadchertar County
(914)593-5575 NYS-ELAP No. 10108
Time/Date Set: ___ Form A-70 (rev 1/96)
Sample Type (circle one): 3^^ 3 J 37 jryt/
Potable 3. Non-Potable Treated Bottle #'s:
2. Non-Potable 4. Other. Chain of Custody? .yes .no
Time/Date Collected:. fl-S'- O I Comments;
Collected By:AJ 1 Agency Code: PWS #:________ Source ID:, Type Descriptor:.
Collected From: Bill to:
Location's/lndividual's Name. Name/Company
Street__________________ Street__________
Citv/SVZio ___________ City/St/Zip______
Identification of Source Phone#:_ -.Fax #:
Col lection Point. I CA, CH. Bl? Check#: Amounts,
BACTERIOLOGICAL ANALYSES ORGANIC P^B^NALYSES ORGANIC NONPOTABLE/SOLIO ANALYSES
Lab#:___________________ __
(circle tests) / i / I
(circle tests)
1. Heterotrophic Plate k IiJTrihalorTOthanes (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 6. Pesticides (507) 6. PCB's (Arochlors) (608/8080)
6. Macroscopic 0 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:______________ _ & 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) I^Base Neutral Extractables (625/8270)
Chlorinated'’: yes no 13. Diquat (549) (J^GC/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)
pH
-iXi—Lt-l—L-----
INORGANIC ANALYSES REQUESTED - Lab#:.
(circle tests)
1. Color 20. Acidity 39. Aluminum 59. Potassium
2. T urbidity 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) 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 O&CO3 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 66. 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. I.IV254 57. Molybdenum 75. tCLP-BNA’s
58. Nickel _
NYC-WTC_000071433
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