Chain of custody record, Westchester County Dept of Labs, Jan

NYC 9/11 Public Portal Document I JTAL SERVICES SAMPLE SUBMISSION FORM ER COUNTY LABORATORIES AND RESEARCH M 2 Dnn.) Rtr.id, Yrit.-ill.i, Now Yurry 10;.yn nn4)231-1G?0 Fox 8514) 2.H-I7/? yj ''liT NYS-ELAP No. 10108 tormA.70 (rev. 10/01)

ft# (III •XT ■2. Non Potable 4. Other „ ,, Chain of Custody? Yes No M hm../l5,m.t;ollt,:t,:o ‘.i ’ ”: 2 J /; ' ' Comments. ' /• L;___L_______ Agency Code; Wb PWS #;Source ID; . ...Type Descriptor: II Collected By; „ J Collected From; Localion’s/lndividuars Name Name/Company Street____ _______________ Street.................. City/St/Zip_____________ ___ H City/SVZip identification of Source Phone#; Fax#; Collection Point V l -vB CA,CH, Bl? J Check#: Amount$_________

BACTERIOLOGICAL. ANALYSIS Lab#;____ _ ___________________ Lab#;.................. .....___________________ ORGANIC POTABLE ANALYSIS: ORGANIC NONPOTABLE/SOLiD ANALYSIS __ Heterotrophic Plate Count Tuhalomnihanes __ Purgeable Halocarbons (624/8260) , (hemodialysis & all others) __ Coliform P/A (Public supplies) _ Volatile Halocarbons (524) __ Purgeabie Aromatics (624/8260) ' Voialilo Aronjatics (t)/-))

■ __ Coliform MPN (priv well, raw, stp) __ roral Coliform (n!’ s.hm,-lm) . Tbwi TritKilomothane Po!ent':ii (hint Microscopic Microextractables (504) Pesticides/PCB screen (508) .. .. M,TcrosGopi.- j ■pCBas 1-0.0,001,rebirth.-,2 lmwai

-Xr:___________ Hert-ieidos 8.15- l -nslicides 8,25 -Cart.ama,ePes,Les (631) . Glycols in Water " RefrlgGraled?____ yea____ no Acid Extractabies (625/8270) _ Glyphosate (547) . Pas,.Ncum,irx!r;uAihias (625/8270) ' Chlorinated;? yes no Fifi! Ciilunni; Ro;.;.................. mg/t.. =SS>0_Byp.„nn«a(66„ y GC/MS unknown Scan _______________ Iota! Chlorine Res;mg/L pH __ ___ _ ______ za5X53:&», „_UCMR List 1 ___________ l^idCHEMtCAL'MjAlYSIS ..„MtBE only (524) ■ .i . ;-Y.. ___________________ ,, , , ... -.......,................. ■ ■;?? i--

INORGANIC ANALYSIS REQUESTED - i.nh/; „ Potassium; z™«y pH _ Bromide ziSEX Arsenic Selenium „ Silver •: __ Conductivity _ Bromate/Chlorate/Chlorite __ Barium . Sodium ; t / __ Corrosivity (temp“C) ___ Chloride ___ Beryllium __ Thallium > ___ __ BOD (5 day) ___ Cyanide —-------- ___ Boron ---- Vanadium '

■ .... Carbr^nacoonsBOD (5dny) ... rinoride -..^-Cadrr!ium __ Calcium, as CaCO-i _. Zinc ^ ------------------------------------------- Cl P Zchromium^Total ~Metals/CN S Volatiles ... Total OnKinirCnrlH.,, . . Nit,open. Nitrite ns N zssr Seiiii-violntiies ' Pf.’H ' Iqc'PC'B'; o Bi ■ Z £S" snnpnn.,on “. .... IKptiOt s Iota! fl . .Copper Iron I liatil isplioi IS, Ortho! tates inqncsujm ■ I

NYC-WTC_000073155