Chain of Custody Record, Sample AE03384, Feb 2002

NYC 9/11 Public Portal Document 5

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM tester I govcom WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 ^11 ) -* (914)231-1620 Fax (914) 231-1772 r * ■ RTMIirT iTX ' X NYS-ELAP No. 10108 Time/Date Set: Form A-70 (rev. 10/01)

Samgile_Type (circle one): C: im I«I lb ,1 4 ir , -2' / 3 \ 1 Potabl£^ '3. Non Potable Treated Bottle rrpf-l^ W. 'STil 2. Non Potable 4. Other Chain of Custody?;___ Yes___ No Time/Date Collected: Comments: KV Collected By: X>. .Sc'15'f V" Agency Code: PWS #:Source ID:. Type Descriptor: 3 Collected From: t —— Bill to: Location's/lndividual’s Name gk/f; i 'yh K Name/Company street Street_______ city/st/zip City/SVZip Identification of Source___________________________ Phone#: Fax#: Collection Point CA,CH, Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:_____________ __ - / // V ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count 1 (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) 1 __ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081) f __ Microscopic __ Microextractables (504) __ PCB’s (Arochlors) (608/8081) __ Macroscopic __ Pesticides/PCB screen (508) _ Herbicides (SMI8/6630,8151) - . _ API' __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SMI8/6630) __ Other:____________________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) >-• ,. __ Pesticides (525) __ Glycols in Water - Refrigereted?yes no __ Carbamate Pesticides (531) __ Acid Extractables (625/8270) Chlorinated:?yes no __ Glyphosate (547) __ Base Neutral Extractables (625/8270) __ Diquat (549) ^,Z^4^C/MS Unknown Scan Free Chlorine Res: . mg/L __ Chlorination Disinfection Byproducts (551) _ Phthalates (606MS) s Total Chlorine Res: . mg/L __ Haloacetic Acids (552) _ Other: ____________________ . _ Other Pesticides (SM18/6630) pH ___________ _UCMRList1 RADIOCHEMICAL ANALYSIS _ MtBE Only (524) Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ /Acidity YUKIuminum __ Potassium __ Turbidity __ Alkalinity /xAntimonv XSeleniurn . -— pH __ Bromide X Arsenic ^Silver ria,.- __ Conductivity __ Bromate/Chlorate/Chlorite 'X Barium __ Sodium ■^1'7 __ Corrosivity (temp:. ?C) __ Chloride X Beryllium Thallium _ BOD (5 day) __ Cyanide __ Boron __ , Vahadj'um __ Carbonaceous BOD (5 day) __ Fluoride XCadmium ' __ 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 XChromium, Total _ Voiatfles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent _ Total Organic Halides __ Semi-violatiles __ Nitrogen, Total Kjeldahl as N V Cobalt __ Solids, Percent (%) __ Pesticides/PCB’s __ Oil and Grease XCopper __ Solids, Settleable __ Phenol 2L Iron __ Solids, Suspended __ Phosphorus Total as P X Lead TCLP _TCLP-Metals _ Solids, Total __ Phosphorus, Ortho as P _ Magnesium •_ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates X Manganese _TCLP-Herbicides __ Solids, Total Volatile __ Surfactants XT Mercury Other: <>' '________ _ TCLP-Volatiles _ UV254 Molybdenum _ TCLP-BNA’s X Nickel

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