Chain of custody record, Westchester County Labs, Feb 2002

NYC 9/11 Public Portal Document rt El ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ( I

i 7 5 tester [ov.com WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 * ’ N;^=ELAP No. 10108 j Time/Date Set: ^^A-70 (rev. 10/01) *

Sample Type (circle one); I I 1. Potable 3. Non Potable Treated Bottle #’s: (£^on Potable 4. Other Chain of Custody? Yes___ No Time/Date Collected: Comments: Collected By: .’ < io I . Agency Code: PWS #:________ Source ID: Type Descriptor: Collected From: Bill to; Location’s/lndividual’s Name Name/Company _ Street_________________ Street_________ City/St/Zip______________ City/St/Zip Identification of Source Phone#:_______ Fax#: Collection Point I CA,CH, Bl? 1- Check#: Amount$. !> t I BACTERIOLOGICAL ANALYSIS Lab#: ________________________ Lab#; 22-^ ORGANIC POTABLE ' ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count i (hemodialysis & all others) __ Trihalomethanes (524) _ Purgeable Halocarbons' (624/8260) __ Coliform P/A (Public supplies) __ Volatile Halocarbons (524) _ Purgeable Aromatics (624/8260) _ Coliform MPN (priv well, raw, stp) _ Volatile Aromatics (524) _i Acrolein & Acrylonitrile (8260)

r __ Fecal Coliform (all samples) __ Microscopic __ Total Trihalomethane Potential (510) __ Microextractables (504) _ Organochlofine Pesticides (608/8081) _ PCB's (Arochlors), (608/8081) i i __ Macroscopic __ Pesticides/PCB screen (508) Herbicides (SM18/6630,8151) _ API __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SMI8/6630) _ Other:____________________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) I ! _ Pesticides (525) __ Glycols in Water .Refrigerated?yes no __ Carbamate Pesticides (531) __ Acid Extractables (625/8270) Chlorinated;?yes no __ Glyphosate (547) ■__ Base Neutral Extractables (625/8270) _ Diquat (549) X-jGC/MS Unknown Scan Free Chlorine Res:___ . mg/L __ Chlorination Disinfection Byproducts (551) ) __ Phthalates (606MS) Total Chlorine Res: .mg/L __ Haloacetic Acids (552) __ Other:____________________________ _ Other Pesticides (SMI 8/6630) pH ___________ _ UCMR List 1 RADIOCHEMICAL ANALYSIS _ MtBE Only (524) .s __ Radon :__Other_____________________

( INORGANIC ANALYSIS REQUESTED - Lab#; __ Color __ Acidity __ Aluminum __ Potassium _ Turbidity _ Alkalinity __ Antimony __ Selenium _ pH. __ Bromide __ Arsenic __ Silver __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium __ Corrosivity (temp:. .°C) __ Chloride __ Beryllium __ Thallium _ BOD (5 day) __ Cyanide __ Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium _ Zinc __ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOa CLP ~ __ 'Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*^ __ Dissolved Oxygen __ Nitrogen, Nitrate as N _ Metals/CN __ Chromium, Total _ Total Organic Carbon __ Volatiles __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Semi-violatiles __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N __ Cobalt __ Pesticides/PCB’s __ Solids, Percent (%) __ Oil and Grease __ Copper __ Solids, Settleable __ Phenol __ Iron __ Solids, Suspended __ Phosphorus Total as P __ Lead ICLE _TCLP-Metals __ Solids, Total __ Phosphorus, Ortho as P _ Magnesium __ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates __ Manganese __ TCLP-Herbicides i? > __ Solids, Total Volatile __ Surfactants __ Mercury _ TCLP-Volatiles __ Other:_________________ _ UV254 __ Molybdenum _ TCLP-BNA’s 1 _ Nickel

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