NYC 9/11 Public Portal Document
r
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
jester WESTCHESTER COUNTY LABORATORIES AND RESEARCH
TOv.com
2 Dana Road, Valhalla, New York 10595
(914) 593-5575 •
^jme/Date Set:
* c - NYS-ELAP No. 10108
Form A-70 (rev. 1/96)
tztl ? -
Sample Type (circle one):
Potable 3. Non Potable Treated Bottle
2. Non Potable 4. Other____________ Chain of Custody?___ yes___ no
Time/Date Collected: Comments:
Collected By: _ "'A^ncy Code: PWS #:______ Source ID: Type Descriptor:
Collected From: BUI to:
Location’s/lndividual’s Name Name/Company
Street________________________ Street________
City/St/Zip____________________ City/St/Zip
Identification of Source Phone#: Fax#:
Collection Point_____
I CA,CH, Bl? Check#: Amounts.
BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLEZSOLID ANALYSIS
Lab#:, Lab#:____
(circle tests) (circle tests)
1. Heterotrophic Plate 1. Trihalomethanes (524) J. Purgeable Halocarbons (624/8260)
Count (hemodialysis & all others) r'2?\ Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260)
2. Coliform P/A (public supplies) VJ3/ Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624)
3. Coliform MPN (priv well, raw, stp) 4. Total Trihalomethane Potential (510) 4. Phthalates (625/8270)
4. Fecal Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8081)
5. Microscopic 6., Pesticides (507) 6. PCB’s (Arochlors) (608/8081)
6. Macroscopic (7,.'Pesticides/PCB screen (508) 7. Methoprene (616)
fcet:________ 8. PCB as Decachlorobiphenyl (508A)
9^ Herbicides (515)
8. Herbicides (EPAI 978/8151)
9. Pesticides (SMI 8/6630)
(io) Pesticides (525) - 10. Petroleum Hydrocarbon Scan (310-13).-.-;
Refrigerated?yes no
11. Carbamate Pesticides (531) 11. Glycols V..,
Chlorinated:? yes no 12. Glyphosate (547) 12. Acid Extractables (625/8270)
13. Diquat (549) 11 Base Neutral Extractables (625/8270)
Free Chlorine Res:. mg/L 14. Chlorination Disinfection Byproducts (551)' Q4)gc/MS Semivolatile Unknown Scan
Total Chlorine Res: mg/L 15. Haloacetic Acids (552) 15. Purgeable Halocarbons (DEF)
16. Pesticides (SMI8/6630) . .16. Purgeable Aromatics (DEF)
pH 17. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB’s (PEF)
18. Other: > • "^{8. Other: ■
INORGANIC ANALYSIS REQUESTED - Lab#: o
(circle tests)
1. Color 20. Ajidity 39. Aluminum 59. Potassiurn «•»>
2. Turbidity 21. Alkalinity, as CaCOs 40. Antimony 60. Selenium v
3. pH 22. Bromide 41. Arsenic 61. Silver j f^l j
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 I
8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOs 46. Calcium, as CaCOs 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-violatiles
12.''Total Organic Halides 31. Nitrogen, Total Kjeldahl as N 50. Cobalt 69. Pesticides/PCB’s
13. Solids, Percent (%) 32. Oil an Grease 51. Copper 70. Disk Deliverables
33. Phenol 52. Iron
f
Solids, Settleable
Solids, Suspended 34. Phosphorus Total as P 53.Lead ICJLE
71 TCLP-Metals
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. UV254 57 Molybdenum
75. TCLP-BNA’s
58. Nickel
NYC-WTC_000071574
OCR can misread numbers and units. Confirm readings against the page image before using them.