NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
(914) 593-5575 NYS-ELAP No. 10108
Time/Date Set: Form A-70 (rev. 1/96)
Sample Type (circle one):
rTr'T^table/ 3. Non-Potable Treated Bottle #’s:^,
2’. 'Non'-’Potable 4. Other. Chain of Custody? .yes no
.'■,L
Time/Date Collected: Comments:
Collected Bv:< ■ ' Agency Code: PWS #:_________ Source ID: Type Descriptor:,
Collected From: Bill to:
Location's/lndividual’s Name Name/Company
Street____________________ Street__________
City/SVZip_______________ ' City/St/Zip.^______
Identification of Source Phone#:________ Fax #:
Collection Point_________ JL-lL 1 CA. CH. Bl? Check#: Amounts.
BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES
Lab#:______________________ Lab #:_______ 7____________________
' (circle tests) (drcle tests)
1. Heterotrophic Plate 1. Trihalomethanes (524) 1. Purgeable Halocarbons.(624/8260)
Count (hemodialysis & all others) 2. Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260)
2. Coliform P/A (public supplies) 3. 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 7. Pesticides/PCB screen (508) 7. Herbicides (SM-18/6640; 8151)
7. API 8. PCB as Decachlorobiphenyl (508A) . 8. Other Pesticides (SM-18/6630)
8. Other:_________ 9. Herbicides (515) ,9. Petroleum Hydrocarbon Scan (310-13)
-vrS ' 7’-
10. Pesticides (525) 10. Glycols in Water
Refrigerated? .yes. .no 11. Carbamate Pesticides (531), 11. Acid Extractables (625/8270)
12. Glyphosate (547) 12. Base Neutral Extractables (625/8270)
Chlorinated?! yes .no 13. Diquat (549) . <' i 3. GC/MS Unknown Scan ,,
.14. Chlorination Disinfection Byproducts (551) 147 Pufgeable Halocarbons (DEF)
Free Chlorine Res: .mg/L; J5. Haloacetic Acids (552) 15. Purgeable Aromatics (DEF)
; ’.'l 6. Other Pesticides (SM-18/6630) 16. Pesticides (DEF)
Total Chlorine Res: .m^L,; . 717. Petroleum/Hydrocarbon Scan (310-13) 17. PCB’s (Arochlors) (DEF)
pH,
INORGANIC ANALYSES REQUESTED ’^Lab#:
(circle tests) ■
1. Color ?G. Acidity 39. Aluminum 59. Potassium
2. Turbidity 21. Alkalinity, as CaCOa 40. Antimony 60. Selenium
3. pH 22. Bromide 41. Arsenic ’ 61. Silver
4. Conductivity ,23. Bromate/Chlorate/Chlorite 42, Barium 6^. Sodium
5. Corrosivity (temp: .“C) ^4. Chloride ., 43. Beryllium 63. Thallium
6. BOD (5 day) 25. (Cyanide 44. Boron "64. Vanadiurn
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 1^
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
13. Solids, Percent (%) 32. Oil and Grease 51. Copper 70. Disk Deliverables
14. Solids, Settleable 33. Phenol 52. Iron ICLP
15. Solids. Suspended 34. Phosphorus. Total as P ■' .5.3: Lead 71. TCLP-Metals
16. Solids. Total 35. Phosphorus, Ortho as P 54. Magnesium 72. TCLP-Pesticides
17. Solids. Total Dissolved 36. Sulfates 55.\Manganeso 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
NYC-WTC_000073126
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