NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
III
UMtchettar County
wlhie/Date Set:
WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
(914) 593-5575 NYS-ELAPNo. 10108 ’
Form A-70 (rev. 1/96)
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Sample Type (circle one):
Bottle #'s:_x22il£12i^dS
1^Potable 3. Non-Potable Treated
Z Non-Potable 4. Other Chain of Custody? yes no
Time/Date Collected: _______ Comments:
Collected By: Agency Code: PWS #:_________ Source ID: Type Descriptor:.
Collected From: Bill to;
Location’s/lndividual’s Name Name/Company
Street_________________________ Street__________
City/SVZip_____________________ City/SVZip______
Identification of Source Phone#: Fax #:
CollectionPoinC 33 I CA, CH, Bl? Check#: Amounts.
BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLIO ANALYSES
Lab#;______________________ L’ab #:_______________________
(circle tests) (drcle 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 Pesticides (507) b '6, PCB’s (Arochlors) (608/8080)
6. Macroscopic Pesticides/PCB screen (508) 7. Herbicides (SM-18/6640; 8151)
IjkAPl 8. PCB a^ecachlorobiphenyl (508A) e." 8. Other Pesticides (SM-18/6630)
Bother;___________________ 9fc Herbicides (515) ,? 9. Petroleum Hydrocarbon Scan (310-13)
<13. Pesticid^(525) •; 10. Glycols in Water
Refrigerated? .yes. no 11. Carbamate Pesticides (531) ■f
11. Acid Extractables (625/8270)
12. Glyphosate (547) 12. Base Neutral Extractables (625/8270) - *
Chlorinated?: .yes. no 13. Diq?iat (549) GC/MS Unknown Scan
14. Chlorination Disinfection Byproducts (551) 14. Purgeable Halocarbons (DEF)
Free Chlorine Res: mg/L 15. Haloacetic Acids (552) , 15. Purgeable Aromatics (DEF)
16. Other Pesticides (SM-18/6630) ? yv 16. Pesticides (DEF)
Total florine Res; 2.2_ mg/L 17. Petroleum/Hydrocarbon Scan (310-)3)^; 17. PCB’s (Arochlors) (DEF)
£H
INORGANIC ANALYSES REQUESTED - Lab#;.
.(circle tests)
1. Color 20. Acidity 39. Aiumiz^rh 59. Potassium
2. Turbidity 21. Alkalinity, as CaCOa 40. Antimr^y. 60. Selenium
3. pH 22. Bromide 41. Arseni^f 61. Silver
4. Conductivity 23. Bromate/Chlorate/Chlorite 42. BariunYf-.T 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 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-volatiles
12. Total Organic Halides 31, Nitrogen, Total Kjeldahl as N 50. Cobalt 69. Pesticides/PCB's
d 1^. Solids, Percent (%) 32. Oil and Grease 51. Copper 70. Disk Deliverables
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. 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:_____________ 38.1. IV254 57. Molybdenum 75. TCLP-BNA’s
58. Nickel
NYC-WTC_000072365
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