Chain of Custody Record, Sample AE03503, Feb 2002

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM hester ^^vcom WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 p NYS-ELAP No. 10108 Time/Date Set: erg f'ii/iY' p - iibi, p- lisir Form A-70 (rev. 10/01)

Sample Type (circle one): (^Potable 3. Non Potable Treated Bottiry^^*- l/ 2 7_ y/ ■ z <■> t/- }ri<4 ] 2. Non Potable 4. Other____________ Chain of Custody? Yes___ No Time/Date Collected: Comments: J Collected By: L ■ Va)o Of? Agency Code: PWS #:________ Source ID: Type Descriptor: Collected From: Bill to: Location’s/lndividual’s Name A/V C ji)rP Name/Company Street I <9 \r-Je i [ a i/c Kr i yC Street_________ City/St/Zip City/SUZip Identification of Source__________ Phone#: Fax#: Collection Point. (3^0 QA 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) j,^olatile 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 (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) _^ase Neutral Extractables (625/8270) __ Diquat (549) 3C/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 List 1 RADIOCHEMICAL ANALYSIS _ MtBE Only (524) __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: ] __ Color __ Acidity x/Aluminum Potassium __ Turbidity __ Alkalinity ^j^ntimonv iZSeleniurn _ pH __ Bromide .rsenic Z Silver j __ Conductivity __ Bromate/Chlorate/Chlorite arium __ ^dium,: __ .Corrosivity (temp:. °C) __ Chloride eryllium iZihallium _ BOD (5 day) __ Cyanide __ Boron Vjnadium __ Carbonaceous BOD (5 day) __ Fluoride jZ^admium tZVinc _ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOa __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N £LP V Calcium, Ca*^ __ Dissolved Oxygen __ Nitrogen, Nitrate as N _.Metals/CN i/Ohromium, Total __ Total Organic Carbon __ Volatiles __ Nitrogen, Nitrite as N Chromium, Hexavalent ^^Jcobalt __ Semi-violatiles __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N Z^Copper __ I Pesticides/PCB’s __ Solids, Percent (%) __ Oil and Grease __ Solids, Settleable __ Phenol jZ^ron t/lead TCLP __ Solids, Suspended __ Phosphorus Total as P __ TCLP-Metals __ Solids, Total __ Phosphorus, Ortho as P __ Magnesium __ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates xZ^anganese __ TCLP-Herbicides /Solids. Total Volatile __ Surfactants if^ercury _ TCLP-Volatiles ' Z Other: ___________ _ UV254 ^Molybdenum _ TCLP-BNAs IZ Nickel

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