NYC 9/11 Public Portal Document
Ill
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
UJostehesterfeonty (914) 593-5575 NYS-ELAP No. 16*108
Time/Date Set:__________ Form A-70 (rev. 1/96)
Sample Type (circle one): LV ■
1y Potable 3. Non-Potable Treated Bottle #’s: 1 '
2. Non-Potable 4. Other______________ Chain of Custody? yes" no
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Time/Date Collected: Comments:
Collected 8y._;____ ( Agency Code: PWS Source ID: Type Descriptor:
Collected From: Bill to:
Location’s/lndividual's Name U Name/Company
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Street__________________ _ ___________ Street___________
City/St/Zip__________ ________________ Citv/St/Zio
Identification of Source Phone#:_________ Fax #:
Collection Point I CA, CH. Bl? Check#: Amounts’
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BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES
Lab#:■ Lab #:__________________________
(circle lests) (circle lests)
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)
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5. Microscopic 6. Pesticides (507) 6. PCB’s (Arochlors) (608/8080)
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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)
I 8. Other; _______________ _ 9. Herbicides (515) !“■ • 9.. Petroleum Hydrocarbon Scan (310-13)
I. 10. Pesticides (525) 10. Glycols in Water
Refrigerated? yes no 11. Carbamate Pesticides (531) 11. Acid Extractables (625/8270) j
12. Glyphosate (547) 12. Base Neutral Extractables (625/8270)
Chlorinated’ : yes no 13. Diquat (549) 13. GC/MS Unknown Scan
r Free Chlorine Res:. mg/L
14. Chlorination Disinfection Byproducts (551)
15. Haloacetic Acids (552)
16. Other Pesticides (SM-18/6630}
14. Purgeable Halocarbons (DEF) I
15. Purgeable Aromatics (DEF)
16, Pesticides (DEF)
Total Chlorine Res: rng/L ‘ 17. Petroleum/Hydrocarbon Scan (310-13) 17. PCB's (Arochlors) (DEF)
pH-__
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INORGANIC ANALYSES REQUESTED - Lab#: . < t Ji /
(circle tests)
1. Color 20. Acidity f 39.'Aluminum 59. Potassium
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2. T urbidity 21. Alkalinity, as CaCOa UO; Antimony r 60. Selenium
, 61. Silver I'
3. pH 22. Bromide {41' Arsenic
4. Conductivity 23i Bromate/Chlorate/Chlorite •,.42. Barium 62. Sodium 'I
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5. Corrosivity (temp: °C) 24. Chloride f43.'Beryllium 63. Thallium
6. BOD (5 day) 25. Cyanide 44. Boron 64. Vanadium
7. •Soluble BOD (5 day) 26. Fluoride 45. Cadmium /iS5.tZinc____________ I
8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOa 46. Calcium, as CaCOa CLP 1 '■
9. Chemical Oxygen Demand 28. Nitrogen, Ammonia as N , 47. Calcium, Ca'^ 66. Metals/CN 1
10. Dissolved Oxygen 29. Nitrogen, Nitrate as N f*48; Chromium, Total 67. Volatiles
11. Total Organic Carbon 30. Nitrogen, Nitrite as N 4'9. Chromium, Hexavalent 68. Semi-volatiles I
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 TCLP
, r ^3.. Lead
15. Solids, Suspended 34. Phosphorus. Total as P 71. TCLP-Metals
J 'l6. Sciids, Total 35. Phosphorus, Ortho as P 54. Magnesium 72. TCLP-Pesticides
17. Solids, Total Dissolved 36. Sulfates 55. Manganese 73. TCLP-Herbicides
. 1 18. Solids. Total Volatile 37. Surfactants 56. Mercury 74. TCLP-Volatiles
19. Other:- 38. I IV254 ' 5.7. Molybdenum 75. TCLP-BNA’s
58. Nickel , I
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NYC-WTC_0C)0074363
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