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 Type (circle one):
1. Potable
3. Non Potable Treated
2. Non Potable
4. Other
Time/Date Collected: 08 3
Collected By: 1: Micio
211/02
Agency Code:
Collected From:
Location's/Individual's Name
рuс
Street
14
BUZAT
(AVE N.
City/SU/Zip
22lhar/la
dentification of Source
Collection Point
DATLAA
V0A- 6354,K.0.19
C-1492
Q:3343.0512,250.20210252)
Bottle #'s:
Chain of Custody?
Yes
Comments:
PWS #:
Source ID:
Bill to:
Name/Company
Street
City/St/Zip
Phone#:
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
Macroscopic
APL
Other:
ORGANIC POTABLE ANALYSIS
Trihalomethanes (524)
LVolatile Halocarbons (524)
LVolatile Aromatics (524)
Total Trihalomethane Potential (510)
Microextractables (504)
Pesticides/PCB screen (508)
PCB as Decachlorobiphenyl (508A)
Herbicides (515)
Pesticides (525)
Refrigerated? _ yes no
Chlorinated:?-
- yes
Free Chlorine Res:
Total Chlorine Res:
_no
mg/L
mg/L
pH
Carbamate Pesticides (531)
Glyphosate (547)
Diquat (549)
Chlorination Disinfection Byproducts(551)
Haloacetic Acids (552)
Other Pesticides(SM18/6630)
UCMR List 1
RADIOCHEMICAL ANALYSIS
MtBE Only (524)
Radon
Other
INORGANIC ANALYSIS REQUESTED - Lab#:
75
- 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
VAntimony
VArsenic
LBarium
Beryllium
Boron
Cadmium
_ Calcium, as CaCO3
Calcium, Ca+2
Chromium, Total
Chromium, Hexavalent
Cobalt
-Copper
Iron
Lead
Magnesium
L Manganese
Mercury
Molybdenum
Nickel
NYC-WTC_000073255
nenc
NYS-ELAP No. 10108
Form A-70 (rev. 10/01)
-4o5y
57,7695
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
LSelenium
Silver
Sodium
LThallium
• Vanadium
L Zinc
CLP
Metals/CN
Volatiles
Semi-violatiles
Pesticides/PCB's
TCLP
TCLP-Metals
TCLP-Pesticides
TCLP-Herbicides
TCLP-Volatiles
TCLP-BNA'S
OCR can misread numbers and units. Confirm readings against the page image before using them.