Chain of Custody Record, Samples AE03434/3454, Feb 2002

NYC 9/11 Public Portal Document

* A CC0 ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM A^^stdiester WESTCHESTER COUNTY LABORATORIES AND RESEARCH govcom 2 Dana Road, Valhalla, New York 10595 (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: 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 Street_______ City/St/Zip_________ City/St/Zip Identification of Source Phone#: Fax#: Collection Point I CA,CH, Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:______________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count __ Trihalomethanes (524) (hemodialysis & all others) __ 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 (SM18/6630,8151) _ API __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SMI8/6630) __ 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 (SMI8/6630) pH _UCMR List 1 RADIOCHEMICAL ANALYSIS __ MtBE Only (524) __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Acidity __ Aluminum __ Potassium __ Turbidity __ Alkalinity __ Antimony __ Selenium _ pH __ Bromide __ Arsenic __ Silver __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium __ 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 CaCOa __ Calcium, as CaCOs __ Chemical Oxygen Demand CLP __ Nitrogen, Ammonia as N __ Calcium, Ca*2 __ Dissolved Oxygen __ Nitrogen, Nitrate as N _ Metals/CN __ Chromium, Total __ Total Organic Carbon __ Volatiles __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Total Organic Halides __ Semi-violatiles __ Nitrogen, Total Kjeldahl as N _ Cobalt __ Solids, Percent (%) __ Pesticides/PCB’s __ Oil and Grease __ Copper __ Solids, Settleable __ Phenol __ Iron tclp __ Solids, Suspended __ Phosphorus Total as P __ Lead _TCLP-Metals '__ Solids, Total __ Phosphorus, Ortho as P __ Magnesium __ Solids, Total Dissolved __ TCLP-Pesticides __ Sulfates __ Manganese __ Solids, Total Volatile __ TCLP-Herbicides __ Surfactants __ Mercury Other:_________________ __TCLP-Volatiles _ UV254 __ Molybdenum _ TCLP-BNA’s __ Nickel

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