NYC 9/11 Public Portal Document
Westchester County
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
(914) 593-5575
Time/Date Set:
Sample Type (circle one):
1) Potable
3. Non-Potable Treated
2. Non-Potable
4. Other
Time/Date Collected: 1500
11-10-61
Collected By: Wagner
Agency Code:
Collected From:
Location's/Individua's Name_ NYC DEP
Street 11 WesiLeke
DRIuC
City/St/Zip_
Volhallo, Ny 10373
Identification of Source
Collection Point C20 CH
ZSArE eeste
Bottle #'s: 6
Chain of Custody?
yes
comments:
PWS#:_
Source ID
Bil to:
Name/Company
Street
City/St/Zip
Phone#:
CA, CH. BI?
BACTERIOLOGICAL ANALYSES
ORGANIC POTABLE ANALYSES
Lab#:
(circle tests)
1. Heterotrophic Plate
Count (hemodialysis & all others)
2. Coliform P/A (public supplies)
3. Coliform MPN (priv well, raw, stp)
4. Fecal Coliform (all samples)
5. Microscopic
6. Macroscopic
7AРL
8 Other:
Refrigerated?
Ves
no
Chiorinated..
Kyes
Free Chlorine Res:
_mg/L
Total Chlorine Res:
mg/L
Lab #:
(circle tests)
1. Trihalomethanes (524)
Volatile Halocarbons (524)
Volatile Aromatics (524)
Total Trihalomethane Potential (510)
5.
Microextractables (504)
Pesticides (507)
Pesticides/PCB screen (508)
8.
PCB as Decachlorobiphenyl (508A)
9.
Herbicides (515)
10 Pesticides (525)
11. Carbamate Pesticides (531)
12. Glyphosate (547)
13. Diquat (549)
14. Chlorination Disinfection Byproducts (551)
15. Haloacetic Acids (552)
16. Other Pesticides (SM-18/6630)
17. Petroleum/Hydrocarbon Scan (310-13)
pH
INORGANIC ANALYSES REQUESTED- Lab#:
(circle tests)
1.
Color
Turbidity
pH
4.
Conductivity
5
Corrosivity (temp:
°C)
6
BOD (5 day)
7
Soluble BOD (5 day)
8
Carbonaceous BOD (5 day)
9. Chemical Oxygen Demand
10. Dissolved Oxygen
11. Total Organic Carbon
12. Total Organic Halides
13. Solids, Percent (%)
14. Solids, Settleable
15. Solids, Suspended
16. Solids, Total
17. Solids, Total Dissolved
18, Solids Total Volatile
19. Other:
20. Acidity
21: Alkalinity, as CaCO,
22, Bromide
23. Bromate/Chlorate/Chlorite
24, Chioride
25. Cyanide
26. Fluoride
27. Hardness, Total as CaCO,
28. Nitrogen, Ammonia as N
29. Nitrogen, Nitrate as N
30. Nitrogen, Nitrite as N
31, Nitrogen, Total Kjeldahl as N
32. Oil and Grease
33. Phenol
34. Phosphorus, Total as P
35. Phosphorus, Ortho as P
36, Sulfates
e7 Surfactants
381JV254
39. Aluminum
40, Antimony
41. Arsenic
42. Barium
43
44
Beryllium
Boron
45 Cadmium
46. Calcium, as CaCOs
47. Calcium Ca*2
48. Chromium, Total
49, Chromium, Hexavalent
L50/ Cobalt
51. Copper
52, Iron
53 l ead
54, Magnesium
55, Manganese
56. Mercury
57 Molybdenum
58. Nickel
NYC-WTC_000070480
NYS-ELAP No. 10108
Form A-70 (rev. 1/96)
X7 и 572
Type Descriptor:
Fax #:
Check#:
Amounts
ORGANIC NONPOTABLE/SOLID ANALYSES
1. Purgeable Halocarbons (624/8260)
2.
Purgeable Aromatics (624/8260)
3.
Acrolein & Acrylonitrile (624)
4.
Phthalates (606/8060)
5.
Organochlorine Pesticides (608/8080)
6. PCB's (Arochlors) (608/8080)
7. Herbicides (SM-18/6640; 8151)
8.
Other Pesticides (SM-18/6630)
9. Petroleum Hydrocarbon Scan (310-13)
10. Glycols in Water
11. Acid Extractables (625/8270)
12 Base Neutral Extractables (625/8270)
13 GC/MS Unknown Scan
14. Purgeable Halocarbons (DEF)
15. Purgeable Aromatics (DEF)
16. Pesticides (DEF)
17, PCB's (Arochlors) (DEF)
metas
59. Potassium
60. Selenium
61. Silver
62. Sodium
63. Thallium
64/ Vanadium
65. Zinc
CLP
66. Metals/CN
67. Volatiles
68. Semi-volatiles
69. Pesticides/PCB's
70. Disk Deliverables
TCLP
71. TCLP-Metals
72. TCLP-Pesticides
73. TCLP-Herbicides
74, TCLP Volatiles
75 TCLP BNA'S
OCR can misread numbers and units. Confirm readings against the page image before using them.