NYC 9/11 Public Portal Document
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
WESTCHESTER COUNTY LABORATORIES AND RESEARCH
1 2 Dana. Road, Valhalla, New York 10595
(914) 593-5575
ie/Date Set:
Sample Type (circle one):
Potable
3. Non-Potable Treated
2/Non-Potable
4. Other
Time/Date Collected:
Colected By: Wogner
1/41
Agency Code:
Collected From:
Location's/Individua's Name MYC DEe
Street 19 Westloke
cıyisvzip Valhalla, Ny los9s
Identification of Source
Collection Point Cat Le C4
Botle PeSR-
Chain of Custody?
Comments:
PWS #:
Bil tọ:
{Name/Company
Street
:City/SV/Zip
Phone#:
CA, CH. BI?
miyes
no
Source, ID:
BACTERIOLOGICAL ANALYSES
ORGANIC POTABLE ANALYSES
Lab#
(circle tests):VA
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 AP"
8. Other:
Refrigerated?
yes.
Chiornated?:_
_yes_
:no.
Free Chiorine Res:
_mg/L
Total Chlorine Res:
mgL:
Lab#
(drcle tests)
Trihalomethanes (524),
Volatile Halocarbons (524)
Volatile Aromatics (524)
Total Tnhalomethane 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)
3. Diquat (549)
14. Chlorination Disinfection Byproducts (551)
415. Haloacetic Acids (552)
i16: Other Pesticides (SM-18/6630)
17. Petroleum/Hydrocarbon Scan (310-13)
INORGANIC ANALYSES REQUESTED-Lab#:_
(circle tests)
2713
1 Color
20, Acidity
2.- Turbidity
21% Alkalinity, as CaCOs
3 pH
22, Bromide
4.
Conductivity
23, Bromate/Chlorate/Chlorite
5.
Corrosivity (temp
°C)
4, Chloride
6.
BOD. (5 day)
25. Cyanide
Soluble BOD (5 day)
26. Fluoride
9:
Carbonaceous BOD (5 day)
27. Hardness, Total as CaCO3
Chemical Oxygen Demand
28. Nitrogen, Ammonia as N:
10, Dissolved Oxygen
29. Nitrogen, Nitrate as N
1l. Total Organic Carbon
30. Nitrogen, Nitrite as N.
12. Total Organic Halides
31. Nitrogen, Total Kjeldahl as N
13: Solids, Percent (%)
32. Oil and Grease
14. Solids, Settleable
33. Phenol
15. Solids. Suspended
34Phosphorus, Total as P.
16. Solids, Total,
35. Phosphorus, Ortho as P
17: Solids Total Dissolved
36. Sülfates
18-Solids Total Volatile
37 Sürtactants
419
Other.
38 UV254
39. Aluminum
Antimony
Arsenic
42
, Barium
Beryllium
"Boron
45. Cadmium
46. Calcium, as Caco"
7l Calcium, Ca"
48.
Chromium, Total
49.
Chromium, Hexavalent
(50. Cobalt
51
Copper
. Iron
53. Lead
4. Magnesiüm
Manganese
Mercury 2
Molybdenum
58
: Nickel20
NYC-WTC_000071384
NYS-ELAP No. 10108
Form A 70 (rev. 1/96)
toldaana
_Type Descriptor:
¿Fax #:
:Check#
•Amount$.
ORGANIC NONPOTABLE/SOLID ANALYSES
1, Purgeable Halocarbons (624/8260)
2 Purgeable Aromatics (624/8260)
Acrolein & Acrylonitrile (624)
4
Phthalates (606/8060):
Organochlorine Pesticides (608/8080)
PCB's (Arochlors) (608/8080)
7
Herbicides (SM-18/6640; 8151)
8
9
Other Pesticides (SM-18/6630)
Petroleum Hydrocarbon Scan (310-13)
10. Glycols in Water
11. Acid Extractables (625/8270)
Base Neutral Extractables (625/8270)
6GC/MS Unknown Scan
14. Purgeable Halocarbons (DEF)
15. Purgeable Aromatics (DEF)
16. Pesticides (DEF)
17. PCB's (Arochlors) (DEF)
59) Potassium
60. Selenium
6.1. Silver
62
Sodium
:Thailium
64) Vanadium
65. Zinc
CLP
66. Metals/CN
67. Volatiles
68. Semi-volatiles
69. Pesticides/PCB's
70. Disk Deliverables
ICLP
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.