NYC 9/11 Public Portal Document
Westchester
gov.com
ENVIRONMENTALSERVICES SAMPLE SUBMISSIONFORM
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
2. Non Potable
4. Other
Time/Date Collected: 0 21- 0 L
05)50
Collected By: D.SC CSTT Agency Code:_
Collected From:
Location's/Individual's Name NYC CLP
Street M WeS+LAKC DOVE
City/St/Zip
VALHALLA, NY 10395
Identification of Source
Collection Point
Cutirtf
NYS-ELAP No. 101
Form A-70 (rev.1/g
19412, 8365, PFB9426, к7497,
Botte Fs: C0315,966, Q9599, 0FB 9441
Chain of Custody? yes no
K8236
1-8320
VCC
Comments:
BLANR
PWS #:
Source ID:
.Type Descriptor:.
Bill to:
Name/Company
Street
City/St/Zip
Phone#:
Fax#:
CA,CH, ВІ?
Check#:
Amount$
BACTERIOLOGICAL ANALYSIS
ORGANIC POTABLE ANALYSIS
ORGANIC NONPOTABLE/SOLID ANALYSIS
Lab#:
(circle tests)
1. Heterotrophic Plate
Count (hemodialysis & all others)
2. Coliform P/4 (public supplies)
3. Coliform MPN(priv well, raw, stp)
4. Fecal Coliform (all samples)
5. Microscopic
6. Macroscopic
7. APL
8. Other:
Refrigerated?
_yes
Chlorinated:? yes no
Free Chlorine Res:
Total Chlorine Res:
mg/L
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)
Pesticides/PCB screen (508)
8.
PCB as Decachlorobiphenyi (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 (Arochiors) (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:
INORGANIC ANALYSIS REQUESTED - Lab#:
21. Alkalinity, as CaCO3
Aumnummetals
C40. Antimony
23. Bromate/Chlorate/Chlorite
5. Corrosivity (temp:
(43.Beryllium
62, Sodium
(63. Thallium
64. Nanadium
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 (%)
14. Solids, Settleable.
15. Solids, Suspended
16. Solids, Tota
17. Solids, Total Dissolved
18. Solids, Total Volatile
19.OtherA
STLT
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 an Grease
33. Phenol
34. Phosphorus Total as P
35. Phosphorus, Ortho as P
36. Sulfates
37. Surfactants
38. UV254
45. Cadmium
46.Calcium, as CaCos
47.Calcium, Ca+?
48. Chromium, Total
49. Chromium, Hexavalent
(50.Cobalt
51. Copper
52,Jron
53.Lead
C54Magnesium
55 Manganese
56. Mercury
57 Molybdenum
58. Nickel
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
NYC-WTC_000072811
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