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)231-1620 Fax (914) 231-1772
Time/Date Set:
Sample Jype (circle one):
1. Potable
3. Non Potable Treated
2. Non Potable
4. Other
Time/Date Collected: 10/S
2•1-02
Collected By: K.0 (1t Ci Agency Code:
Collected From:
Location's/Individual's Name
Street
City/St/Zip
Vaha lla
LuC. DeP
1AVC
Drue
l0s0S
G
Identification of Source
Collection Point
CRo - 1
VDA: 0175
G- 2548,335
Bottle #'s:
Chain of Custody?
Comments:
PWS #:.
Billto:
Name/Company
Street
City/St/Zip
Phone#:
24
_YesNo
Source ID:
CA,CH, BI?
BACTERIOLOGICAL ANALYSIS
Lab#:
Lab#:
Heterotrophic Plate Count
(hemodialysis & all others)
Coliform P/A (Public supplies)
Coliform MPN (priv well, raw, stp)
Fecal Coliform (all samples)
Microscopic
Macroscopie
AP!
Other:_
Refrigerated? _ yes _ no
Chlorinated:?
. yes_ no
Free Chlorine Res:_
-mg/L
Total Chlorine Res:
-mg/L
pH
ORGANIC POTABLE ANALYSIS
Trihalomethanes (524)
/Volatile Halocarbons (524)
Volatile Aromatics (524)
Total Trihalomethane Potential (510)
Microextractables (504)
Pesticides/PCB screen (508)
PCB as Decachlorobiphenyl (508A)
Herbicides (515)
Pesticides (525)
Carbamate Pesticides (531)
Glyphosate (547)
Diquat (549)
Chlorination Disinfection Byproducts (551)
Haloacetic Acids (552)
Other Pesticides (SM18/6630)
cites (SM 13830)
UCMR List 1
MtBE Only (524)
RADIOCHEMICAL ANALYSIS
Radon
Other
25
INORGANIC ANALYSIS REQUESTED - Lab#:
_ Color
Turbidity
_ рH
Conductivity
Corrosivity (temp:_
BOD (5 day)
Carbonaceous BOD (5 day)
Soluble BOD (5day)
Chemical Oxygen Demand
Dissolved Oxygen
Total Organic Carbon
Total Organic Halides
Solids, Percent (%)
Solids, Settleable
Solids, Suspended
Solids, Total
Solids, Total Dissolved
Solids, Total Volatile
Z Other:
- Acidity
Alkalinity
Bromide
°C)
Bromate/Chlorate/Chlorite
Chloride
Cyanide
Fluoride
Hardness, Total as CaCO3
Nitrogen, Ammonia as N
Nitrogen, Nitrate as N
Nitrogen, Nitrite as N
Nitrogen, Total Kjeldahl as N
Oil and Grease
Phenol
Phosphorus Total as P
Phosphorus, Ortho as P
Sulfates
Surfactants
UV254
Z Aluminum
Antimony
LArsenic
v Barium
L'Beryllium
Boron
Cadmium
Calcium, as CaCO3
Calcium, Ca*2
Chromium, Total
Chromium, Hexavalent
Cobalt
LCopper
kfron
kLead
Magnesium
Manganese
Mercury
L Molybdenum
•Nickel
NYC-WTC_000073253
neac:
NYS-ELAP No. 10108
Form A-70 (rev. 10/01)
Type Descriptor:
Fax#:
Check#:
Amount$
ORGANIC NONPOTABLE/SOLID ANALYSIS
Purgeable Halocarbons (624/8260)
Purgeable Aromatics (624/8260)
Acrolein & Acrylonitrile (8260)
Organochlorine Pesticides (608/8081)
PCB's (Arochlors) (608/8081)
Herbicides (SM18/6630,8151)
Other Pesticides (SM18/6630)
Petroleum Hydrocarbon Scan (310-13)
Glycols in Water
Acid Extractables. (625/8270)
Base Neutral Extractables (625/8270)
GC/MS Unknown Scan
Phthalates (606MS)
Other:
Potassium
Selenium
LSilver
Sodium
- Thallium
Vanadium
Zinc
CLP
Metals/CN
Volatiles
Semi-violatiles
Pesticides/PCB's
TCLP
TCLP-Metals
TCLP-Pesticides
TGLP-Herbicides
TCLP-Volatiles
TCLP-BNAS
OCR can misread numbers and units. Confirm readings against the page image before using them.