NYC 9/11 Public Portal Document
County
CSROL-
ENVIRONMENTAL SERVICEȘ SAMPLE SUBMISSION FORM
WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
(914) 593-5575
e/Date Set:
Sample Type (cirçle one):
1, Potable
: 3. Non-Potable Treated
2. Non-Potable
4. Other.
Time/Date Collected: D930
11*1-0/
Collected By:
NEWMAN
Agency Code:
Collected From:
Location's/Individual's Name
NYe DEP/EENSICO
Street
M7WESTLL
DRIVE
City/SV/Zip
VALHALLA, NV 10595
Identification of Source
Collection Point_
:CATLEFF
Bottle #'s:
Chain of Custody?
Comments:
PWS #:
Bill to:
Name/Company
Street
City/SV/Zip
Phone#:
CA, CH, BI?
yes
-no
Source ID:
BACTERIOLOGICAL ANĄLYSES
Lab#:
(cirçle tesis)
1 Heterotrophic Plate
Count (hemodialysis & all others)
2. Coldeim PIA (public supplies)
3. Coliform MPN (priv well, raw, stp)
4 Fecal Coliform (all sämples)
5. Microscopic
. 6. Macroscopic
Refrigerated? A
yesd
•. no
Chionnated?:
_yes
no
Free Chlorine Res:
mg/L
Total Chlorine Res:
mg/L
ORGANIC POTABLE ANALYSES
Lab #:
Uciicle tests)
Trihalomethanes (524)
Volatile Halocarbons (524)
Volatile Aromatics (524)
Total Trihalomethane Potential (510)
5.
Microextractables (504)
Pesticides (507)
Pesticides/PCB screen (508)
PCB as Decachlorobipheny! (508A)
Herbicides (515)
Pesticides (525)
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)
INORGANIC ANALYSES REQUESTED - Lab#:
(circle tests)
1.
Color
2.
3.
Turbidity
pH
Conductivity
Corrosivity (temp:
°C)
BOD (5 day)
7.
Soluble BOD (5 day)
Carbonaceouș BOD (5 day)
9. Chemical Oxygen Demand
10. Dissolved Oxygen
: 11. Total Organic Carbon
12. Total Organic Halides
Solids, Percent (%)
Solids, Settleable
3. Solids, Suspended
16. Solids: Total
17. Solids, Total Dissolved
18. Solids, TotalVolatile
19 Other:2-
26845
20. Acidity
21. Alkalinity, as CaCO3
22. Bromide
23. Bromate/Chlorate/Chlorite
24. Chloride
25: Cyanide
:26. Fluoride
27. Hardness, Total as CaCOs
128. 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 LV254
39. Aluminum
40.Antimony
41: Arsenic
42.Barium
43, Beryllium
44. Boron
45. Cadmium
46
Calcium, as CạCOs
Calcium, Cat?
48. Chromium, Total
4g-Chromium, Hexavalent
50. Cobalt
51 Copper
52 Iron
3. Lead
)Magnesium
55) Manganese
56 Mercury
57 Molybdenum
58.- Nickele
NYC-WTC_000071163
10 52
NYS-ELAP No. 10108
Form A-70 (rev. 1/96)-**
Type Descriptor:
Fax#:
Check#:
Amount$
ORGANIC NONPOTABLE/SOLID ANALYSES
1.
Purgeable Halocarbons (624/8260)
2.
Purgeable Aromațics (624/8260)
3.
4.
Acrolein & Acrylonitrile (624):
Phthalates (606/8060)
5..
Organochlorine Pesticides (608/8080)
6.
.PCB's (Arochlors) (608/8080)
7.
Herbicides (SM-18/6640; 8151),
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 Scạn
14. Purgeable Halocarbons (DEF)
15. Purgeable Aromatics (DEF)
16. Pesticides (DEF)
17. PCB's (Arochlors) (DEF)
Astats
59. Potassium
60. Selenium
6.h; 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
Z1TCLP-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.