Chain of Custody Record, Sample AE03384, Feb 2002

NYC 9/11 Public Portal Document I ! ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM 1 stiCtiester I ggovcom WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 o /1 \ -* (914)231-1620 Fax (914) 231-1772 < LLJSbHEkiSAMLI X NYS-ELAP No. 10108 Time/Date Set; FormA-70(rev.10/01)

Sami le (circle one): ^>1 i WI>/, K:ir rW}- T Potablg.*,--* 3. Non Potable Treated; Bottle #’s: 2. Non Potable 4. Other Chain of Custody?___ Yes No f

I Time/Date Collected: 0^0 i Comments: Collected ByP --*5 CcTTT Agency Code: PWS #:______ Source ID: Type Descriptor:____ Collected From: Bill to: Location’s/lndividual’s Name _ Name/Company Street Street_______ City/St/Zip V A:; CH f u L tV City/St/Zip ■[ Identification of Source Phone#: Fax#: Collection Point______ CA,CH, Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:_______________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/ SOLID ANALYSIS __ Heterotrophic Plate Count (hemodialysis & all others) __ Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) __ Coliform P/A (Public supplies) -^.-Volatile Halocarbons (524) _ , Purgeable Aromatics (624/8260) 2>Afolatile Aromatics (524) _ Acrolein & Acrylonitrile (8260) __ Coliform MPN (priv well, raw, stp) __ 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 (SM18/6630;8151) _ API __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SMI 8/6630) , - __ Other:_____________________ _ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) 1 __ 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) 2 GC/MS Unknown Scan Free Chlorine Res; . mg/L __ Chlorination Disinfection Byproducts (551) _ Phthalates (606MS) ■ I Total Chlorine Res: . mg/L _ Haioacetic Acfds (552) - Other;___________ __ Other Pesticides (SM18/6630) pH ___________ _UCMR List1 RADIOCHEMICAL ANALYSIS _MtBE Only (524) __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color _ Acidity Yt. Aluminum _ Potassium __ Turbidity __ Alkalinity > Antimony Selenium — pH __ Bromide j;/ Arsenic Z^ilver A. __ Conductivity __ Bromate/Chlorate/Chlorite Barium ____ ) - ,v . __ Corrosivity (temp: .“C) __ Chloride 'IZ^Beryllium _2< Thallium !* .* x. f _ BOD (5 day) __ Cyanide _ Boron __ Vanadibm >•- ri __ Carbonaceous BOD (5 day) __ Fluoride .^Cadmium Zinc _ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOs ¥ CLP __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*^ __ Dissolved Oxygen __ Metals/CN __ Nitrogen, Nitrate as N .Xphromium, Total __ Total Organic Carbon __ Nitrogen, Nitrite as N ._ Volatifes __ Chromium, Hexavalent __ Semi-violatiles __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N X Cobalt __ Pesticides/PCB’s __ Solids, Percent (%) __ Oil and Grease XCopper __ Solids, Settleable __ Phenol Xlron I£LP __ Solids, Suspended __ Phosphorus Total as P JSLead _TCLP-Metals _ Solids, Total __ Phosphorus, Ortho as P _ Magnesium __ TCLP-Pesticides _ Solids, Total Dissolved __ Sulfates XL Manganese __ TCLP-Herbicides __ Solids, Total Volatile __ Surfactants ’X Mercury

i X. Molybdenum __ TCLP-Volatiles ’^ZT’Other: /Q _ UV254 ■ _ TCLP-BNA's _2^Nickel

NYC-WTC_000073641