Chain of Custody Record, Sample AE03384, Feb 2002

NYC 9/11 Public Portal Document

! 1 y ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM f stehester ^govcom WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 1 < LJLJLSMUdkdkaHlJ X (914)231-1620 Fax (914)231-1772 NYS-ELAP No. 10108 Time/Date Set: Form A-70 (rev. 10/01)

Sample Type (circle one): 1. Potable :3. Non Potable Treated Bottle #'s: MM Fl 2. Non Potable 4. Other. Chain of Custody? Yes No ■ Time/Date Collected::1 Comments: Collected By: Agency Code: mMiZE PWS #:________ Source ID; Type Descriptor: Collected From: Bill to: I Location’s/lndividual’s Name luHd bl Ml'- • Name/Company Street ______________ Street_________ City/St/Zip______________ City/SVZip Identification of Source Phone#:_______ Fax#: Collection Point CA.CH, Bl? Check#; Amounts.

I BACTERIOLOGICAL ANALYSIS Lab#: Lab#:_______________________ ORGANIC POTABLE ANALYSIS I ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count __ Trihalomethanes (524) I ■ (hemodialysis & all others) __ Purgeable Halocarbons (624/8260) I __ Coliform P/A (Public supplies) __ Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform MPN (priv well, raw, stp) __ Volatile Aromatics (524) _ Acrolein & Acrylonitrile (8260) ! __ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) _ Organochlorine Pesticides (608/8081) I I __ Microscopic __ Microextractables (504) __ PCB’s (Arochlors) (608/8081) ( __ Macroscopic __ Pesticides/PCB screen (508) _ Herbicides (SMI8/6630,8151) _ 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) X GC/MS Unknown Scan Free Chlorine Res: . mg/L * __ Chlorination Disinfection Byproducts (551) _ Phthalates (606MS) I Total Chlorine Res; . mg/L __ Haloacetic Acids (552) __ Other:__________________________ __ Other Pesticides (SM18/6630) pH ___________ _UCMRList 1 RADIOCHEMICAL ANALYSIS _MtBE Only (524) ! f __ Radon , __ Other c INORGANIC ANALYSIS REQUESTED - Lab#: eu -• __ Color __ /Acidity __ Aluminum __ Potassium __ Turbidity __ Alkalinity __ Antimony __ Selenii^ _ pH __ Conductivity __ Bromide __ Bromate/Chlorate/Chlorite __ Arsenic __ Barium __ Silver __ Sodium ^U'j __ 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 CaCOs CLP __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*^ _ Metals/CN __ Dissolved Oxygen __ Nitrogen, Nitrate as N __ Chromium, Total 1 _ Volatiles __ Total Organic Carbon __ 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 TCkP _TCLP-Metals __ Solids, Total __ Phosphorus, Ortho as P _ Magnesium TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates __ Manganese __ TCLP-Herbicides __ Solids, Total Volatile __ Surfactants __ Mercury _ TCLP-Volatiles __ Other:_________________ _ UV254 __ Molybdenum _ TCLP-BNA's __ Nickel

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