NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM S
HI
UlMlchMter County
Time/Date Set:_________
WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla. New York 10595
(914)593-5575 NYS-ELAP No. 10108
J ~
Form A-70 (rev. 1/96) ''^
Sample Type (circle one):
l.£Potaijl«^ 3. Non-Potable Treated Bottle #'s:^ f-‘ .z7
2. Non-Potable 4. Other ____________ __ Chain of Custody? yes no
Time/Date Collected: " d Z--7 Comments;
Collected B^:^/z Agency Code: PWS #:_________ Source ID; Type Descriptor;.
Collected From: Bill to:
Location’s/lndividual’s Name M f. M d Name/Company
Street______________________ Street__________
City/St/Zip__________________ City/St/Zip
Identification of Source________ Phone#:, Fax #:
Collection Point. z d F^aTch^bp^Z Check#; Amounts.
BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES
Lab#': ‘ -> r'. • ■_______ __ , Lab #. >
. (circle tests) • . ' , j (circle teste). ’> 1 / / I
1.,Heterotrophic Plate Trihalom'etha(^S‘(5£4)/- 1. Purgeable Halocarbons (624/8260)
Count (hemodialysis & all others) Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260)
2. Coliform P/A (public supplies) iSr 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 . 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:T .. Herbicides (515) 9. Petroleum Hydrocarbon Scan (310-13)
^Pesticides (525) 10. Glycols in Water
Refrigerated? .yes. .no IT Carbamate Pesticides (531) 11. Acid Extractables (625/8270)
T2. Glyphosate (547) 12k Base Neutral Extractables (625/8270)
Chlorinated?: .yes. no •13. Diquat (549) 5j)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 ResS '"^"'"--■mq/L 17. Petroleum/Hydrocarbon Scan (310-13) 17. PCB’s (Arochlors) (DEF)
INORGANIC ANALYSES REQUESTED i^Lab#:
(circle tests)
1. Color ‘2D'. Aridity 39. Aluminum 59. Potassium
2. Turbidity 2.1. Alkalinity, as CaCOa 40. Antimony 60. Selenium
3. pH Bromide 41. Arsenic 61. Silver
4. Conductivity 2’3. Bfomate/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 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. I.IV254 57. Molybdenum 75. TCLP-BNA’s
58. Nickel
NYC-WTC_000071434
OCR can misread numbers and units. Confirm readings against the page image before using them.