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
Bottle #'s:
2. Non-Potable
4. Other
Time/Date Collected:
090
T:mgn/
Chain of Custody? _
Comments:
Collected By:
NEIIMAN
Agency Code:
PWS#:
Collected From:
Location's/Individual's Name
NYC DEP/KENICO NamerCompany
19 IVeS+44
Apve
Street
City/St/Zip
lhe
NT
10595
City/St/Zip
Identification of Source
Phone#
Collection Point
CROGH
CA, CH. BI?
yes_no
Source ID:
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
7. API
8. Other:
Refrigerated?
yes_
Chiorinated?:yes
Free Chtorine Res:_
_mg/L
Total Chlorine Res
_mg/L
Lab #:
(circle tests)
1. Trihalomethanes (524)
2. Volatile Halocarbons (524)
Volatile Aromatics (524)
4.
Total Trihalomethane Potential (510)
Microextractables (504)
6
Pesticides (507)
Pesticides/PCB screen (508)
8.
PCB as Decachlorobiphenyl (508A)
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
рH
Conductivity
Corrosivity (temp:
°C)
BOD (5 day)
Soluble BOD (5 day)
Carbonaceous BOB (5 day)
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 CaCO3
22. Bromide
23. Bromate/Chlorate/Chlorite
24. Chloride
25. Cyanide
26. Fluoride
27. Hardness, Total as CaCO3
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
37. Surfactants
38. LIV254
-7874
39. Aluminum
40. Antimony
41. Arsenic
42. Barium
(43/Beryllium
44. Boron
45. Cadmium
46. Calcium, as CaCO3
(47.Calcium, Ca*
48. Chromium, Total
49. Chromium, Hexavalent
50/ Cobalt
51
Copper
Iron
53. Lead
54, Magnesium
55. Manganese
56. Mercury
57) Molybdenum
58. Nickel
NYC-WTC_000070609
NYS-ELAP No. 10108
Form A-70 (rev. 1/96)-
1487058
,Pr6-909,516
Type Descriptor
Fax#:
Check#
Amount$
ORGANIC NONPOTABLE/SOLID ANALYSES
1.
Purgeable Halocarbons (624/8260)
Purgeable Aromatics (624/8260)
3.
Acrolein & Acrylonitrile (624)
Phthalates (606/8060)
6.
OrganochlorinePesticides (608/8080)
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
T4. Purgeable Halocarbons (DEF)
15. Purgeable Aromatics (DEF)
16. Pesticides (DEF)
17. PCB's (Arochlors) (DEF)
Metdo
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.