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
UtoctehMtarCourty (914) 593-5575 NYS-ELAP No. 1010^
Time/Date Set: Form A-70 (rev. 1/96)
Sample Type (circle one): Y” 773,77 b 77q 6
3. Non-Potable Treated Bottle #’s:0 - Z.M <, A 7 ; ALt
1. PotaBtex
■^’^ori’Pbfable 4. Other_____________ Chain of Custody? .yes no
Time/Date Collected:, Comments:
■K? ;(
Collected By: — _______ Agency Code; PWS #:_________ Source ID: Type Descriptor:.
Collected Froin: /-/. fa Bill to:
Location’s/lndiviJual's Name l z. V z y “7 " .'i
Name/Company
Street_____________ Street__________
City/St/Zip__________ City/St/Zip >*
Identification of Source. Phone#: —Fax#:
<n I CA. CH Bl? Check#: Amounts.
Collection Point -■
V.,
BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLIDANALYSES
Lab#:.______________________ Lab #:_______________________
(circle tests) (circle tests)
PI®'® 1. Trihalomethanes (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)' 145 Total Trihalomethane Potential (510) 4. Phthalates (606/8060)
4. Fecal Coliform (all samples) 5. Microextractabies (504) 5. Organochlorine Pesticides (6Qfi^080)
5. Microscopic 6^ Pesticides (507) '6. PCB's (Arochlors) (608/8080)W':
6. Macroscopic Q Pesficides/PCB screen (508) ■;.7. Herbicides (SM-18/6640; 81%^.,.,
7. AP! - ( >■ PCB as Decachlorobiphenyl (508A) 8. Other Pesticides (SM-18/6630)^
8. Other:,1 9,.,^ Herbicides (515)
Pesticides (525)
Refrigerated? yes no Ik Carbamate Pesticides (531) 11. Acid Extractables (625/8270)',
12. Glyphosate (547) ^Base Neutral Ej^Vdctables (625/8270) d tf
Chlorinated?: .yes no 13. Diquat (549) (^GC/MS Unkriov^can .,
14. Purgeable Halc^^ons (DEF) .Vl
14. Chlorination Disinfection Byproducts (551) .■th..
Free.Chlorine Res:. mg/L 15. Haloacetic Acids (552) 15. Purgeable Arorr^'cs (DEF)
16. Other Pesticides (SM-18/6630) 16. Pesticides (DEF)X,
Total,Chlorine Res: mg/L-y‘ 17. Petroleum/Hydrocarbon Scan (310-13) 17. PCB’s (Arochlors) (DEF) at/
..if
a. -iv a/ -
pH..? -J
INORGANIC ANALYSES REQIUKTEDa’Lab#:_________ ; I
/’$■ <■"
(circle tests)
1. Color z Agdity 39. Aluminum
■ '59. PotAssiuf^f^. . h-
2. Turbidity
3. pH
21. AK’alinity, as CaCOa
22. Bromide
40. Antimony
41. Arsenic
60. Selenitim a '/
61. Silver f -7-
'•■"''ll
■■
4. Conductivity B.fbThate/Chlorate/Chlorite 42. Barium 6^. 'Sodium {\
5. Corrosivity (temp:. ?C) ^4: Chloride 43. Beryllium /.^TH&lliunt ■' '
6. BOD (5 day) 2^1 Cyanide 44. Boron
7. Soluble BOD (5 day) 26. Fluorid'e 45. Cadmium '®S8^2inc___________ 'I.
8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOs 46. Calcium, as CaCOa CLP V’
47. Calcium. Ca*-’
v
9. Chemical Oxygen Demand 28. Nitrogen, Ammonia as N 66. Metals/CN
' 10. Dissolved Oxygen 29. Nitrogen, Nitrate as N 48. Chromium, Total 67. Volatiles
■f-
11. Total Organic Carbpp 5 30. Nitrogen, Nitrite as N 49. Chromium, Hexavalent €8. Semi-volatiles
12. Total Organic Halide<y 31. Nitrogen, Total Kjeldahl as N 50. Cobalt 69/ Pesticides/PCB's If <
13. Solids, Percent (“Af „ 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. JCLP-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. UV254 57. Molybdenum 75. TCLP-BNA’s
58. Nickel
‘.r .
NYC-WTC_000071536
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