NYC 9/11 Public Portal Document
Westchester
gov.com
•ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
(914) 593-5575
ne/Date Set:
Sample Type (circle one):
1.Potable
3. Non Potable Treated
2. Non Potable
4. Other
Time/Date Collected:
0hoa
Collected By:
Ne nimьr
Collected From:
Location's/Individual's Name
Street
City/St/Zip
Identification of Source
Collection Point
EaT CCE
N/as/or
Agency Code: _
NYCDF PluensiC
PASCH
Le: Drvve
Lholla
10595
TrC-C/06
2168
Bottle #'s:
Chain of Custody?
Comments:
PWS#:-
Bill to:
Name/Company
Street
City/St/zip
Phone#t:
yes suua no
Source ID:_
CA,CH, BI?
BACTERIOLOGICAL ANALYSIS
ORGANIC POTABLE ANALYSIS
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)
Microscopic
iacroscopic
API
8. Other:
Refrigerated?
Chlorinated:?
yes
_ no
Free Chlorine Res:
Total Chlorine Res: _
yes no
mg/L
_mg/L
рH
Lab#:
(circle tests)
1. Trihalomethanes (524)
2.
Volatile Halocarbons (524)
Volatile Aromatics (524)
4. Total Trihalomethane Potential (510)
5. Microextractables (504)
Pesticides (507)
ДPOredODOR aтe soo
8. PCB as Decachlorobiphenyl (508A)
9, Herbicides (515)
1Q) Pesticides (525)
11. Carbamate Pesticides (531)
12. Glyphosate (547)
13. Diquat (549)
14. Chlorination Disinfection Byproducts (551)
15. Haloacetic Acids (552)
16. Pesticides (SM18/6630)
17. Petroleum/Hydrocarbon Scan (310-13)
18. Other:
INORGANIC ANALYSIS REQUESTED - Lab#:
(circle tests)
1. Color
2. Turbidity
3. 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
Solids, Percent (%)
Solids, Settleable
. Solids, Suspended
16. Solids, Total
17. Solids, Total Dissolved
18. Solids, Total Volatile
19. Other:
20. Acidity
21. Alkalinity, as CaGO3
22. Bromide
23. Bromate/Chlorate/Chlorite
24. Chloride
25. Cyanide
26. Fluoride
27. Hardness, Total as CaCOs
28. Nitrogen, Ammonia as N
29. Nitrogen, Nitrate as N
30. Nitrogen, Nitrite as N
31. Nitrogen, Total Kjeldahl as N
32. Oil an Grease
33. Phenol
34. Phosphorus Total as P
35. Phosphorus, Ortho as P
36. Sulfates
37. Surfactants
38. UV254
21173
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.Oobalt
51.Copper
5a fron
53.Lead
54 Magnesium
55 Manganese
56: Mercury
57 Molybdenum
58. Nickel
NYC-WTC_000072021
NYS-ELAP No. 10108
Form A-70 (rev.1/96)
, OFBOI
N1S7
Type Descriptor:
Fax#:
Check#:_
Amount$
ORGANIC NONPOTABLE/SOLID ANALYSIS
1. Purgeable Halocarbons (624/8260)
2. Purgeable Aromatics (624/8260)
3. Acrolein & Acrylonitrile (624)
4. Phthalates (625/8270)
5. Organochlorine Pesticides (608/8081)
6. PCB's (Arochlors) (608/8081)
7. Methoprene (616)
8. Herbicides (EPA1978/8151)
9. Pesticides (SM18/6630)
10. Petroleum Hydrocarbon Scan (310-13)
11. Glycols
12. Acid Extractables (625/8270)
13. Base Neutral Extractables (625/8270)
14.GC/MS Semivolatile Unknown scan
15. Purgeable Halocarbons (DEF)
16. Purgeable Aromatics (DEF)
17. Pesticides/PCB's (DEF)
18. Other:
Metd
59. Potassium
60. Selenium
61. Silver
62. Sodium
63. Thallium
64. Vanadium
65. Zinc
CLP
66. Metals/CN
67. Volatiles
68. Semi-violatiles
69. Pesticides/PCB's
70. Disk Deliverables
TCLP
71.TCLP Metals
72, TCLP-Pesticides
73. TCLP-Herbicides
74, TCLP,Volatiles
75, TCLP-BNAS
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