Chain of Custody Record, Sample AE03471, Feb 2002

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM JUfestchester «; govcom WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 1 [Art Ja (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; s 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 CA.CH, Bl? Check#: Amounts

BACTERIOLOGICAL ANALYSIS Lab#; s' 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) ‘ I __ 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 (SM18/6630) I pH ------------------- _UCMRList 1 RADIOCHEMICAL ANALYSIS _MtBEOnly (524) J __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: ‘--Z __ Color __ A:idity __ 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 __ Nitrogen, Ammonia as N __ Calcium, Ca*2 Sp __ Dissolved Oxygen __ Nitrogen, Nitrate as N _Metals/CN __ Chromium, Total __ 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 TC LP __ Solids, Suspended __ Phosphorus Total as P __ Lead _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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