Chain of Custody Record, Sample AE03384, Feb 2002

NYC 9/11 Public Portal Document 1 j 1T ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM hester WESTCHESTER COUNTY LABORATORIES AND RESEARCH lux TIJ. ■ - 2 Dana Road, Valhalla, New York 10595 0/1 _ .w < ' " "TwTb IiiIiiTW X (914)231-1620 Fax (914) 231-1772 NYS-ELAPNo. 10108 Time/Date Set: Form A-70 (rev. 10/01)

^mple Type (circle one); >^2^, ■z-z' I I iTpotable^ 3. Non Potable Treated "^2. Ndri''Potable , ^4. Other Chain of Custody?Yes___ No f C) Time/Date Collected: 2-0-0 2 Comments: Collected By; P' tAgency Code: PWS #:_____ _ Source ID: Type Descriptor: Collected From: Bill to: Location’s/lndividual’s Name C Ot Name/Company j Street t VC Street________ i City/St/Zip City/St/Zip Identification of Source^..,^—____________ Phone#: Fax#: Collection Point_____ ( I CA,CH, Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS Lab#: ______________________ Lab#: - % z/ a'U ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count (hemodialysis & all others) __ Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) Volatile Halocarbons (524) _ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) Volatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) __ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081) __ Microscopic __ Microextractables (504) _ PCB’s (Arochlors) (608/8081) __ Macroscopic __ Pesticides/PCB screen (508) _ Herbicides (SMI 8/6630,8151) _ API __ PCB as Decachlorobiphenyl (508A) Other Pesticides (SM18/6630) __ Other:___________ ;_________ — Herbicides (515) __ Petroleum Hydrocarbon Scan-(310-13) — 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) GC/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 (SM18/6630) pH ___________ _UCMRList 1 RADIOCHEMICAL ANALYSIS _MtBEOnly (524) __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Acidity V Aluminum __ . Potassiui^y __ Turbidity _ Alkalinity y Antimony _ pH __ Bromide 2 Arsenic __ Conductivity __ Bromate/Chlorate/Chlorite Barium Sodjum 5"- ' ■“ __ Corrosivity (temp:. ’C) __ Chloride 2 Beryllium 1/Thallium — BOD (5 day) __ Cyanide __ Boron • Vanadium __ Carbonaceous BOD (5 day) __ Fluoride Cadmium X zinc 7 — Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOs A __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N ■ Calcium, Ca*2 CLE _ Metals/CN __ Dissolved Oxygen __ Nitrogen, Nitrate as N XChromium, Total __ Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Senii-violatiles __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N X Cobalt 2 Copper __ Pesticides/PCB’s __ Solids, Percent (%) __ Oil and Grease __ Solids, Settleable __ Phenol / Iron __ Solids, Suspended __ Phosphorus Total as P K Lead TCLP _TCLP-Metals __ Solids, Total __ Phosphorus, Ortho as P — Magnesium _ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates Manganese __ TCLP-Herbicides Solids, Total Volatile __ Surfactants k Mercury _TCLP-Volatiles X Other:f _ UV254 £ Molybdenum _ TCLP-BNA’s X Nickel

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