Chain of Custody Record, Sample AE03388, Feb 2002

9/1 IPuttic portal Dccumen, !

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH I 2 Dana Road, Valhalla, New York 10595 (914) 231-1620 Fax (914) 231-1772 r I ■ Wwfa i iThf 1 ~r NYS-ELAP No. 10108 1 Time/Date Set: Form A-70 (rev. 10/01) i 1/-.5A - -7- i' / 7 2/ Y,, / (5 Sample Type (circle one): <1. Potai^ 3. Non Potable Treated Bottle #'s: J_______________ —-r________ -____________ 2. Non Potable 4. Other Chain of Custody?___ Yes No Time/Date Collected: Comments: Collected By: . Agency Code; PWS #:______ Source ID: Type Descriptor: ( Collected From: Bill to: Location’s/lndividual's Name Name/Company Street i '7 f r.______ Street________ City/St/Zip V 7V ? -yC 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) -'Volatile Halocarbons (524) _ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) _^olatile Aromatics (524) __ Coliform MPN (priv well, raw, stp) __ 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 (SM18/6630,8151) _ 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) _i<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 ------------------- _UCMR Listi RADIOCHEMICAL ANALYSIS _ MtBE Only (524) __ Radon __ Other_________________ _

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Acidity _*fAluminum __ Potassium __ Turbidity __ Alkalinity Antimony j^Selenium. / . - __ Bromide « _ pH t .^Arsenic ^Silver - __ Conductivity __ Bromate/Chlorate/Chlorite _i,crBarium __ Sodipm __ Corrosivity (temp:, .°C) __ Chloride _hf^eryllium jc^fThaljium _ BOD (5 day) __ Cyanide __ Boron __ Vanadium __ Carbonaceous BOD (5 day)- __ Fluoride _*^Cadmium _ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOs __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium. Ca*2 _ Metals/CN ' __ Dissolved Oxygen __ Nitrogen, Nitrate as N _i^hromium, Total _ Volatiles i__ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Semi-violatiles 1__ Total Organic Halides __ Nitrogen, Total Kjeldahl as N _^Cobalt _ Pesticides/PCB's __ Solids, Percent (%) __ Oil and Grease _i::'Copper __ Solids, Settleable __ Phenol u^lron Solids, Suspended __ Phosphorus Total as P ^ead I£LE _TCLP-Metals _ Solids, Total __ Phosphorus, Ortho as P __ Magnesium L Solids, Total Dissolved __ TCLP-Pesticides __ Sulfates ^^anqanese _TCLP-Herbicides Solids, Total Volatile __ Surfactants c-Mercurv _ TCLP-Volatiles ’smother: >;X _ UV254 _i^Wolybdenum _ TCLP-BNA’s I _i£:'Nickel

NYC-WTC_OOOO73662