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:
nelc
NYS-ELAP No. 10108
Form A-70 (rev.10/01)
Sample Type (circle one):
(.Potable.)
3.Non Potable Treated
2. Non Potable
4. Other
Time/Date Collected:
2905
Collected By: R.C
Lи22
2-1.02
Agency Code:
Collected From:
Location's/Individual's Name Nyc. Arl
Street_
4 LоRA
&MKE DE
City/St/Zip
Unlhalla
Ry 1055
Identification of Source
Collection Point PV/ 18
12550, 255 P
Paepuyen
Bottle #'s:
Chain of Custody?Yes No
Comments:
PWS #: _
Source ID:
Bill to:
Name/Company
Street
City/St/Zip
Phone#: .
Fax#:
Type Descriptor:
CA,CH, BI?
Check#:
Amount$
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
Macroscopic
API
Other:
Refrigerated?
yes
Chlorinated:2
yes no
Free Chiorine 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)
UCMR List 1
MtBE Only (524)
ORGANIC NONPOTABLE/SOLID ANALYSIS
Purgeable Halocarbons (624/8260)
Purgeable Aromatics (624/8260)
Acrolein & Acryionitrile (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.
RADIOCHEMICAL ANALYSIS
Radon
Other
INORGANIC ANALYSIS REQUESTED - Lab#:
Color
Turbidity
pH
Conductivity
Corrosivity (temp:
°C)
BOD (5 day)
Carbonaceous BOD (5 day)
Soluble BOD (5 day)
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
Other:
Acidity
Alkalinity
Bromide
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
Aluminum
Antimony
Arsenic
LBarium
Beryllium
Boron
Cadmium
Calcium, as CaCO3
Calcium, Ca*2
Chromium, Total
Chromium, Hexavalent
_Cobalt
LCopper
-Iron
LLead
Magnesium
4Manganese
Mercury
Molyodenun
/Nickel
Potassium
- Selenium
L Silver
Sodium
• Thallium
Vanadium
L Zinc
CLP
Metals/CN
Volatiles
Semi-violatiles
Pesticides/PCB's
TCLP
TCLP-Metals
TCLP-Pesticides
STCLP-Herbicides
TCLP-Volatiles
TCLP-BNAS
NYC-WTC_000073254
OCR can misread numbers and units. Confirm readings against the page image before using them.