NYC 9/11 Public Portal Document
SI
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
tester WESTCHESTER COUNTY LABORATORIES AND RESEARCH
novwm
2 Dana Road, Valhalla, New York 10595
(914) 593-5575
NYS-ELAP No. 10108
le/Date Set:
Sample Type (circle one):
Bottle #’s; d f Q ff
1. Potable 3. Non Potable Treated
2. Non Potable 4. Other____________ Chain of Custody?___ yes___ no
Time/Date Collected:: /Of Comments:____________________________________________
Collected By:____ L Agency Code: PWS #:______ Source ID: Type Descriptor:
Collected From; Bill to:
Location's/lndlvidual’s Name '5 Y Name/Company
Street______________________ Street_______
City/St/Zip___________________ City/St/Zip
Identification of Source Phone#: Fax#:
Collection Point_______ Amounts.
CA.CH, Bl? Check#:
BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS
Lab#:_______________________ Lab#:________________________
(circle tests) (circle tests)
1. Heterotrophic Plate 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) <3/ 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)
^^acroscopic (2? Pesticides/PCB screen (508) 7. Methoprene (616)
Wpi 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151)
8. Other:________ ____________ Herbicides (515) 9. Pesticides (SMI 8/6630),
Refrigerated?yes
Chlorinated:? yes___ no
no
§ Pesticides (525)
Carbamate Pesticides (531) ■:
12. Glyphosate (547)
10. Petroleum Hydrocarbon Scan (310-13)
11. Glycols
12. Acid Extractables (625/8270)
13. Diquat (549) IX Base Neutral Extractables (625/8270)
Free Chlorine Res:. mg/L 14. Chlorination Disinfection Byproducts (551) ^^GC/MS Serriivolatile Unknown Scan
total Chlorine Res: 15. Haloacetic Acids (552) 15. Purgeable Halocarbons (DEF)
mg/L
16. Pesticides (SM18/6630) 16. Purgeable Aromatics (DEF)
pH : 17. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB’s (DEF)
18. Other:_______ ___ ______________ 18. Other: ^.jj
IITaWW J
INORGANIC ANALYSIS REQUESTED - Lab#.
(circle tests)
1. Color 20. Acidity 39. Aluminum 59. Potassium
2. Turbidity 21. Alkalinity, as CaCOs 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
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
^3. Solids, Percent (%) 32. Oil an Grease 51. Copper 70. Disk Deliverables
Solids, Settleable 33. Phenol 52. Iron
n5. Solids, Suspended 34. Phosphorus Total as P 53.Lead ICkP
71 .TCLP-Metals
16. Solids, Total 35. Phosphorus, Ortho as P 54 Magnesium
55 Manganese ' 72.TCLP-Pesticides
17. Solids, Total Dissolved 36. Sulfates
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
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NYC-WTC_000071824
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