NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
2ster WESTCHESTER COUNTY LABORATORIES AND RESEARCH
& ov.com
2 Dana Road, Valhalla, New York 10595
(914) 593-5575
NYS-ELAP No. 10108
i/Date Set: , Form A-70 (rev.1/96)
---- - 7 / , 5'7 7 ?
Sample Type (circle one);
i. Potable 3. Non Potable Treated Bottle#’6:-
' 2. Non Potable 4. Other Chain of Custody?___ yes___ no
Time/Date Collected:/O ■ 7 2 '<• f 9'^1 /k Comments;__________________
Collected By: Agency Code: PWS #: Source ID: Type. Descriptor:
Collected From: Bill to:
Location’s/lndividual’s Name _ Name/Company
Street___________________ J ' Street
City/St/Zip________________ ..'.City/St/Zip____
A-*:, . •
Identification of Source _____________ Phone#; Fax#:
Collection Point _ /b x" >. Check#:
BACTERIOLOGICAL ANALYSIS
Lab#;______________________ _
(circle tests) ;(^letests)'
1. Heterotrophic Plate IT Trihalomethan'es (524)* ' 4’ 1. Purgeable Halocarbons *(624/8260)
Count (hemodialysis & all others) Volatile Halocarbon's' (524) ‘ ‘ ‘ ' 2. Purgeable Aromatics (624/8260)
2. Coliform P/A (public supplies) Volatile Aromatics, (524)' .■ 3. Acrolein & Acrylonitrile (624)
3. Coliform MPN (privwell, raw.stp) 4. Total Trihalomethane Potential (510) 4. Phthalates (625/8270)
4. Fecal Coliform (all samples) ■ 5. ‘ Micrbextractables (504) 5. Organochlorine Pesticides'(608/8081)' Q
5. Microscopic ' e.' Pesticides (507) <4 ■ 6. PCB’s (Arochlors) (608/8081) , ; .,5,
6. Macroscopic ( 7i Pesticides/PCB screen (508) 7. Methoprene (616)
8.' PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151)
8. Wrer: 9. Herbicides (515) " ' 9. Pesticides (SM18/6630)
(10,'- Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13) .
Refrigerated?yes ___ no
11. Carbarnate Pesticides' (531) 11. Glycols
Chlorinated;? yes___ no 12. Glyphosate (547) 12. Acid Extractables (625/8270) d
13. Diquat (549) 13. Base Neutral Extractables (625/8270)
Free Chlorine Res:. mg/L 14. Chlorination Disinfection Byproducts (551) 114)GC/MS Semivolatile Unknown Scan
mg/L 15. Haloacetic Acids (552) 15. Purgeable Halocarbons (DEF)
Total Chlorine Res:
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) 39. Alurhinum I/WlFc1 ( ■< «
1. Color 20. Acidity J 59. Potassium
2. Turbidity 21. Alkalinity, as CaCOa 40. Antiiflbny 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 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
13. Solids, Percent (%) 32. Oil an Grease 51. Copper 70. Disk Deliverables
l^^lids. Settleable 33. Phenol .... - 52. Iron
I^Pblids, Suspended 53.Lead ICLP
34. Phosphorus Total as P
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. Nicjcel to
At*..
NYC-WTC_000072761
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