NYC 9/11 Public Portal Document
111
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
UtMtchMW County NYS-ELAP No. 10108
(914)593-5575
Time/Date Set: ________________________________ Form A-70 (rev. 1/96)
Sample Type (circle one);
. '^l J Potable 3. Non-Potable Treated Bottle #'s: '
'“Z Non-Potable ■ 4. Other_____________ Chain of Custody? yes no
Time/Date Collected: Comments;
Collected By:. t______ Agency Code; PWS ______ Source ID: Type Descriptor;.
Collected From: -■ Bill to: " “
Location’s/lndividual’s Name Name/Company
Street . ' ' ' '_________ Z________ . Street________ _
Citv/St/Zip _______ :____________________ City/Sl/Zip
Identification of Source___________________ : Phone#: _______ Fax #:
( CA, CH Bl? Check#: Amounts.
Collection Point
BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES
Lab#: ■ ' •
Lab ,. '
(drclelesis) , } S,'’J'' (circle tests) / /I / .
1. Heterotrophic. Plate." \ • - 1. Trihalometl^es (^4f * 1. Purgeable Halocarbons (624/8260)
Count (hemodialysis & all others) Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260)
2. Coliform P/A/(public supplies). . f Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624)
3. Coliform MpN^priv well, raw, stp)
7 4. Total Trihalomethane Potential (510) 4. Phthalates (606/8060)
4. Fecal Coriform (all samples) : 5. Microextractables (504) 5. ’Organochlorine Pesticides (608/8080)
Pesticides (507) 6. PCB's (Arochlors) (608/8080)
5. Microscopic' .<'
6. Macroscopic?';"" vi.; ,.
7. API
•
, ,
■,
I) Pesticides/PCB screen (508)
8. PCB as Decachlorobiphenyl (508A)
7. Herbicides (SM-18/6640; 8151)
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) 1Z Base Neutral Extractables (625/8270)
Chlorinated?; ' - ves ' nd ' 13. Diquat (549) ((pGC/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
INORGANIC ANALYSES 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; .°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
‘l7. 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-WfcZ000071435
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