NYC 9/11 Public Portal Document
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ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
(914) 231-1620 Fax (914) 231-1772
NYS-ELAP No. ltfl08
Time/Date Set: •: '-/I'' Form A-70 (rev.10/01)
Sample Type (circle one); 'sS'i ivw
(1,..Potable 3. Non Potable Treated Bottle #’s: P - ■’ t ' i •/ . V
I
2. Non Potable 4. Other Chain of Custody?___ Yes No
Time/Date Collected: - * O j K* i ■'
4 Comments:
Collected By: lAU' L Agency Code: PWS #:_______ Source ID: Type Descriptor:
I
Collected From: Bill to:
Location’s/lndividual's Name Name/Company
Street____________________ Street_________
City/St/Zip______________ __ City/St/Zip
Identification of Source Phone#: Fax#:
Collection Point V
CA,CH, Bl? Check#: Amounts
3 BACTERIOLOGICAL ANALYSIS
Lab#:___________________________
Lab#:
ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS
__ Heterotrophic Plate Count
__ Trihalomethanes (524) __ Purgeable Halocarbons (624/8260)
(hemodialysis & all others)
__ Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260)
__ Coliform P/A (Public supplies)
___ Coliform MPN (priv well, raw, stp) __ Volatile Aromatics (524) __ Acrolein & Acrylonitrile (8260)
__ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081)
__ Microscopic __ Microextractables (504) __ PCB’s (Arochlors) (608/8081)
__ Macroscopic __ Pesticides/PCB screen (508) _ Herbicides (SM18/6630,8151)
y' __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SMI8/6630) ‘
I' _ API
__ Other:_____________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13)
__ Pesticides (525) __ Glycols in Water
Refrigerated?yes 2 no __ Carbamate Pesticides (531) __ Acid Extractables (625/8270)
Chlorinated:? yes no __ Glyphosate (547) __ Base Neutral Extractables (625/8270)
__ Diquat (549) _ xGC/MS Unknown Scan
Free Chlorine Res: . mg/L __ Chlorination Disinfection Byproducts (551) Phthalates (606MS)
Total Chlorine Res: . mg/L __ Haloacetic Acids (552) __ Other:_______________________________
__ Other Pesticides (SM18/6630)
pH-----------------------
_UCMRList1
RADIOCHEMICAL ANALYSIS _MtBEOnly (524)
• ___ Radon
__ Other_______________________
J ^-7
INORGANIC ANALYSIS REQUESTED - Lab#:
__ Color __ Acidity Aluminum __ Potassium
__ Turbidity __ Alkalinity IrS Antimony x^Selenium
_ pH __ Bromide ./Arsenic Silver
__ Conductivity __ Bromate/Chlorate/Chlorite / Barium __ Sodium
Corrosivity (temp: °C) __ Chloride -/Beryllium ji^'Thallium
_ BOD (5 day) __ Cyanide __ Boron __ Vanadium
__ Carbonaceous BOD (5 day) __ Fluoride 2__Cadmium . ./Zinc
_ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOa “CLP
__ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca+2
J^Chromium, Total _Metals/CN
__ Dissolved Oxygen __ Nitrogen, Nitrate as N
__ Volatiles'
__ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent
__ Semi-violatiles
__ Total Organic Halides __ Nitrogen, Total Kjeldahl as N ^YjDobalt
-•"’Copper __ Pesticides/PCB's
__ Solids, Percent (%) __ Oil and Grease
__ Solids, Settleable __ Phenol —/Iron
TCLP
's. __ Solids, Suspended __ Phosphorus Total as P LL Lead
_TCLP-Metals
_ Solids, Total __ Phosphorus, Ortho as P __ Magnesium
JzZj^^Manganese __ TCLP-Pesticides
__ Solids, Total Dissolved __ Sulfates
__ TCLP-Herbicides
__ Solids, Total Volatile __ Surfactants Mercury
»_/other:_______ _ TCLP-Volatiles
_ UV254 2(1 Molybdenum
_ TCLP-BNA's
Nickel
NYC-WTC_000073782
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