NYC 9/11 Public Portal Document
UI
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
UlertchortBf County NYS-ELAP No. 10108
(914)593-5575
Time/Date Set: Form A-70 (rev. 1/96)
Sample Type (circle one):
1. Potable 3. Non-Potable Treated Bottle ~
2. Non-Potable 4. Other______________ Chain of Custody? .yes no
Time/Date Collected:. Comments:
Z ' / A I i v .■'Agency Code: PWS #:__________ Source ID:, Type Descriptor:.
Collected Bv: >
Collected From: Bill to;.
Location’s/lndividual’s Name_ jVujZllM Name/Company__
Street_______ __ ____________________________ Street___________
City/St/Zip___________________________________ City/St/Zip_______
Identification of Source_______________________ Phone#:_________ ________ Fax #:
Collection Point S ■ I CA, CH, Bl? Check#: Arnount%
BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES
Lab#:_________________________ Lab #:___________ 2__________________
(circle lesls) (circle lesls)
1. Heterotrophic Plate JL Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260)
Count (hemodialysis & all others) Sf* 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 (606/8060)
4. Fecal Coliform (all samples) . 5. Microextractables (504). 5. Organochlorine Pesticides (608/8080)
5. Microscopic A Pesticides (507) 6. PCB’s (Arochlors) (608/8080)
6. Macroscopic Pesticides/PCB screen (508) 7. Herbicides (SM-18/6640; 8151)
8. PCB as Decachlorobiphe^l (508A) 8. Other Pesticides (SM-18/6630)
7. API
8. Other:______________________ 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) 5
12. Glyphosate (547) Base Neutral Extractables (625/8270)
Chlorinated?: yes .no ■13. Diquat (549) GC/MS Unknown Scan
14. Chlorination Disinfection Byproducts (551) TA. 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 s _17. Petroleum/Hydrocarbon Scan (310; 13) ’ 17. PCB’s (Arochlors) (DEF) *1,0
INORGANIC ANALYSES REQUESTED -^ab#:
(circle tests)
i2i^ A^dity
1. Color 39. Aluminum 59. Potassium
2. Turbidity . 2T':'Alkalinity, as CaCOa 40. Antimony 60. Selenium I
3. pH ,2^ Bijgmide 41. Arsenic 61. Silver 3
4. Conductivity 23. B.r^mate/Chlorate/Chlorite 42. Barium 62. Sodium
5. Corrosivity (temp: .°C) 24: Chloride 43. Beryllium 63. Thallium
6:- BOD (5 day) ••2&. Cyanide 44. Boron 64. Vanadiurri
7. Soluble BOD (5 day) 26. Fluoride 45.) Cadmium 65. Zinc i
8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOa 46. Calcium, as CaCOs CLP J
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- Chromiunft. Hexavalent 68. Semi-volatiles
12. Total Organic Halides 31. Nitrogen, Total KjeldalH^Tn 50. Cobaltf’lt* 69. Pesficides/PCB’s
13. Solids, Percent (%) 32. Oil and Grease 51. Copper z 70. Disk Deliverables
14. Solids, Settleable 33. Phenol 52. Irori ISLE
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_000071532
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