NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
ster WESTCHESTER COUNTY LABORATORIES AND RESEARCH
ivcom
2 Dana Road, Valhalla, New York 10595
(914) 593-5575
NYS-ELAP No. 10108
(/Date Set; Form A-70 (rev. 1/96)
^mple Type (circle one): 2 ; 7 I 1 ' r / yr:"
I<
(T^otable 3. Non Potable Treated Bottle #’s:_________ ' , '2 f i z c- / '■/ - ,
2. Non Potable 4. Other Chain of Custody? yes no
Time/Date Collected:, // Comments:
Collected By: a L Agency Code: PWS #:___________ Source ID; Type Descriptor:
Collected From: Bill to:
Location’s/lndividual’s Name Name/Company
Street___________________________________ Street____________
City/St/Zip______________________________ City/St/Zip_________
Identification of Source , > -Afcaz. Phone#;__________ Fax#:
Collection Point ■ - ■■ L? / ^21^ CA.CH, Bl? Check#; Amounts,
BACTERIOLOGICAL ANALYSIS' ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS
Lab#:____ Lab#;______________________
(circle tests)
-4^ (circle tests)
1. Heterotrophic Plate 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) 4. Total Trihalomethane Potential (510) 4. Phthalates (625/8270)
4. Fecal Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8081)
5. Microscopic » Pesticides (507) 6. PCB’s (Arochlors) (608/8081)
e^^roscopic § Pesticides/PCB screen (508)
8. PCB as Decachlorobiphenyl (508A)
7. Methoprene (616)
8. Herbicides (EPAI 978/8151)
8. Other:. Herbicides (515) 9. Pesticides (SMI 8/6630)
Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13)
Refrigerated?yes___ no
11. Carbamate Pesticides (531) 11. Glycols
Chlorinated:? yes no 12. Glyphosate (547) 12. Acid Extractables (625/8270)
13. Diquat (549) 13. Base Neutral Extractables (625/8270)
Free Chlorine Res:. mg/L 14. Chlorination Disinfection Byproducts (551) (^. GC/MS Semivolatile Unknown Scan
Total Chlorine Res: mg/L 15. Haloacetic Acids (552) 15. Purgeable Halocarbons (DEF)
16. Pesticides (SM18/6630) 16. Purgeable Aromatics (DEF)
pH 17. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB’s (DEF)
18. Other:__________________________ 18. Other:.
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 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
^^olids. Percent (%) 32. Oil an Grease 51. Copper 70. Disk Deliverables
I^Bolids, Settleable 33. Phenol 52. Iron
TCLP
i^^olids. 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. UV254 57 Molybdenum
75. TCLP-BNA's
58. Nickel
NYC-WTC_000071903
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