NYC 9/11 Public Portal Document
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ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
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Dv.com WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
(914) 593-5575
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NYS-ELAP No. 10108
Form A-70 (rev.1/96)
Sample Type (circle one):
I'. Pota^le ;3. Non Potable Treated Bowe
2.NQi$'Potable 4. Other__________________________ Chain of Custody?___ yes no
Tirrie/Date.i^lected: Comments:
C^Hecf^d ^7^ Agency Code: PWS #:______ Source ID: Type Descriptor.
^dlecte^ From':; Bill to;
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^’^opation's/lndividual’s N^e. A/a/ Name/Company
Street________
; City/^ip - City/St/Zip " 7* V•
Identification of . Phoned Fax#:''
Collection Point- Zb cn I'CACH.'BI?^t^W ^Check#:? ^YgXXmoijn^ ‘
BACTERIOLOGIC^^SltsiS
ORGANIC POTABLE ANALYSIS
Lab#:________ ' • ■ Lab#: -n < I '
(circle tests)
1 . Heterotrophip l^tB. . 1. Trihalomethanes (524) : , 1.-Purgeable Halocarbons‘ (624/8260) D
Count (hemodialj^fs’& all others) ^^TD/olatile Halocarbons (524) 2. Purgeable Aromatics (624/8260) i.
2. Coliform P/A^pui^ si^liOs) 13. Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624)
3. Coliform MPf^ (pqv w^, raw, stp) /t: Total Trihalomethane Potential (510) 4. Phthalates (625/8270)
4. Fecal Coliforrn (a/V^rfiples) 5. Microextractables (504) 5. Organochlorine Pesticides,(608/8081)
I. Microscopic 6. Pesticides (507) 6. PCB’s (Arochlors) (608/8081)
?'Microscopic
8. Other:
/TV Pesticides/PCB screen (508)
8. PCB as Decachlorobiphenyl (508A)
9^ Herbicides (515)
7. Methoprene (616)
8. Herbicides (EPAI 978/8151)
9. Pesticides (SMI8/6630)
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10. Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13)
Refrigerated? yes no
Tf 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 ’“D
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 (DEF)
18. Other:__________________ __ 18. Other:___________ __ ____________
INORGANIC ANALYSIS REQUESTED - Lab#:
(circle tests)
1. Color 20. /'cidity 39;Alun^num ' 59. Potassium
2. Turbidity 21. Alkalinity, as CaCOa 40. Antirnony 60. Selenium {
3. pH 22. Bromide 41. Arsenic 61. Silver
4. .Conductivity 23. Bromate/Chlorate/Chlorite 42. Barium 62. Sodium
5; Cgrro^ity^temp; >------- ®C) 24. Chloride 43. Beryllium 63. Thallium
^ 6. BOD(5d^;^aE 25. Cyanide 44. Boron 64. Vanadium 1
7. Soluble. BOD (^d^ / 26. Fluoride 45. Cadmium 65. Zinc
8. Carbonaceous BOB''‘(^day) 27. Hardness, Total as CaCOa 46. Calcium, as CaCOs GLP
9. Chemical Oxygen Deitiarid -4 ■ 28. Nitrogen, Ammonia as N 47. Calcium, Ca*^ 66. Metals/CN 5t
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
lolids, Percent (%) 32. Oil an Grease 51. Copper 70. Disk Deliverables
iolids, Settleable 33. Phenol 52. Iron
TCLP
15. Solids, Suspended 34. Phosphorus Total as P 53.Lead
71 TCLP-Metais
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_000072446
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