NYC 9/11 Public Portal Document
HL
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
UlM«BheMar(bur«y ’ (914) 593-5575 NYS-ELAP No. 10108
^le/Date Set; Form A-70 (rev. 1/96)
Sample Type (circle one):
1.'/Potable 3. Non-Potable Treated Bottle #’s:p_:____
2. Non-Potable 4. Other Chain of Custody? yes no
Time/Date _______ ) Comments:
Collected Ry: 5SZ;/U / regency Code: PWS #;_________ Source ID: Type Descriptor:
Collected From: Bill to;
Location's/lndividual’s Name. f\} J Name/Company
Street__________________ Street__________
City/St/Zip__________ __ City/SVZip______
Identification of Source Phone#: Fax #;
Collection Point. a • .f I CA, CH, Bl?. Check#; Amounts.
BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES
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) 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'^ 6. Pesticides (507) '6,-’ PCB's (Arochlors) (608/8080)
6. Macroscopic Pesticides/PCB screen (508) 7, Herbicides (SM-18/6640; 8151)
.I^AP! EL PCB as Decachlorobiphenyl (508A)' ‘i 8. Other Pesticides (SM-18/6630)
^^^Other;______________ £___ ^Herbicides (515) ' ■ 9. Petroleum Hydrocarbon Scan (310-13)
QflJ Pesticides (525) 10. Glycols in Water
Refrigerated? yes • no 11. Carbamate Pesticides (531) 11. Acid Extractables (625/8270)
12. Glyphosale;.(547)' 12. Base Neutral Extractables (625/8270)
Chlorinated?: yes no 13. Diquat (549) f^GC/MS Unknown Scan
14. Chlorination Disinfection Byproducts (551) r4; 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. f 17. Petroleum/Hydrocarbon Scan ;(310-bsi, 17. PCB's (Arochlors) (DEF)
pH ■ . . 4’W
INORGANIC ANALYSES REQUESTED - Lab#;.
(circle tests)
1. Color 20. Acidity 39. Alu'minfrp 59. Potassium
2. Turbidity 21. Alkalinity, as CaCOa 40. Antimd^; 60. Selenium
3. pH 22. Bromide 41. Arsbni^^v 61. Silver
4. Conductivity 23. Bromate/Chlorate/Chlorite 42. Barium^;"^ 62. ^dium
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 Ct£
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-volatiles
12. Total Organic Halides 31. Nitrogen, Total Kjeldahl as N' *' 30.''Cobalt 69. Pesticides/PCB's
Solids, Percent (%) 32. Oil and Grease SKCqpper 70. Disk Deliverables______
flBl. Solids, Settleable 33. Phenol ISLE
15. Solids, Suspended 34. Phosphorus. Total as P 53. 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
A.
NYC-WTC_000072364
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