NYC 9/11 Public Portal Document
Westchester
gov.com
ne/Date Set:
ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
1,Dcuched
(914) 593-5575
Wionsay'g
1273
NYS-ELAP No. 10108
Form A-70 (rev.1/96)
Sample Type (circle one):
(1) Potable
3. Non Potable Treated
2. Non Potable
4. Other
Time/Date Collected: 09-
Collected By: Wanger
Agency Code: _
Collected From:
Location's/Individual's Name NyC DFP
Street 19 WesiLaKe Drive
City/StZip Valhalla
- Ny 10595
Identification of Source
Collection Point_CRO GH
40281
QFB 9853.48279 4 826
oea102y a7a paegaai Paar!
Chain of Custody? yes no
Comments:
PWS#: _
Source ID:
Type Descriptor:
Bill to:
Name/Company
Street
City/St/Zip
Phone#:
Fax#:
CA,CH, BІ?
Check#:
Amount$
BACTERIOLOGICAL ANALYSIS
ORGANIC POTABLE ANALYSIS
ORGANIC NONPOTABLE/SOLID 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)
5. Microscopic
Macroscopic
PI
8. Other:
Refrigerated?
Chlorinated:?
Free Chlorine Res:
yes
yes
Total Chlorine Res:
2no
- nо
_mg/L
mg/L
pH
Lab#:
(circle tests)
1. Trihalomethanes (524)
2. Volatile Halocarbons (524)
3. Volatile Aromatics (524)
4. Total Trihalomethane Potential (510)
5. Microextractables (504)
6. Pesticides (507)
7) 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. Pesticides (SM18/6630)
17. Petroleum/Hydrocarbon Scan (310-13)
18. Other:
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. PetroleumHydrocarbon 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:
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
13. Solids, Percent (%)
Solids, Settleable
Solids, Suspended
16. Solids, Total
17. Solids, Total Dissolved
18. Solids, Total Volatile
9 other: Sa, Ti
20. Acidity
21. Alkalinity, as CaCO3
22. Bromide
23. Bromate/Chlorate/Chlorite
24. Chloride
25. Cyanide
26. Fluoride
27. Hardness, Total as CaCOз
28. Nitrogen, Ammonia as N
29. Nitrogen, Nitrate as N
30. Nitrogen, Nitrite a§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 y
38. UV254
39. Auminum LutalS
59. Potassium
40. Antimony
60. Selenium
41. Arsenic
61. Silver
42. Barium
62. Sodium
(43)Beryllium
63>Thallium ®
44. Boron
Vanadium"
45. Cadmium
Zinc
46. Calcium,as CaCOs
CLP
47. Calcium, Ca*2
66. Metals/CN
48. Chromium, Total
67. Volatiles
49. Chromium, Hexavalent
68. Semi-violatiles
(50)Cobalt
69. Pesticides/PCB's
51. Copper
70. Disk Deliverables
52. Iron
53.Lead
TCLP
71.TCLP-Metals
54 Magnesium
55 Manganese
72. TCLP-Pesticides
56. Mercury
73. TCLP-Herbicides
74, TCLP-Volatiles
57 Molybdenum
58. Nickel
75. TCLP-BNA'S
NYC-WTC_000072581
OCR can misread numbers and units. Confirm readings against the page image before using them.