Chain of Custody Record, Sample AE03503, Feb 2002

NYC 9/11 Public Portal Document J. ?X" ■' r

1 i>» ACCn, ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 I I........ (914)231-1620 Fax (914)231-1772 1 NYS-ELAP No. 10108 Time/Date Set: Form A-70 (rev. 10/01)

Sample Type (circle one): 1. Potable I 3. Non Potable Treated Bottle #’s; "I Y 5 r / ib 2. Non Potable 4. Other Chain of Custody?___ Yes___ No I Time/Date Collected: Comments: Collected By: [ H" 1 > Agency Code: I v hUk.- PWS #:______ Source ID: Type Descriptor; Collected From: Bill to: I ........................... Location’s/lndividual’s Name Name/Company Street_________________ Street_______ I City/St/Zip______________ City/St/Zip Identification of Source Phone#: Fax#: i Collection Point VlZlLz CA,CH, Bl? Check#: Amounts. 1 BACTERIOLOGICAL ANALYSIS Lab#: ? Lab#:_______________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS Heterotrophic Plate Count I (hemodialysis & all others) __ Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) __ Coliform P/A (Public supplies) __ Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) _ t 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) _J 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) 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 _UCMRList 1 RADIOCHEMICAL ANALYSIS _MtBEOnly (524) __ Radon __ Other______________________

INORGANIC ANALYSIS REQUESTED - Lab#: _L Color __ Acidity __ Aluminum __ Potassium __ Turbidity __ Alkalinity __ Antimony __ Selenium t pH __ Bromide __ Arsenic __ Silver _i Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium / _ Corrosivity (temp: .°C) __ Chloride __ Beryllium __ Thallium Z/' I BOD (5 day) __ Cyanide __ Boron __ Vanadium Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Zinc __ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOa ~CLP _i Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*^ _ Metals/CN _1 Dissolved Oxygen __ Nitrogen, Nitrate as N __ 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 I Solids, Percent (%) __ Oil and Grease __ Copper _ Solids, Settleable __ Phenol __ Iron I Solids, Suspended __ Phosphorus Total as P __ Lead TCLE _TCLP-Metals _L Solids, Total __ Phosphorus, Ortho as P . _ Magnesium __ TCLP-Pesticides ■ Solids, Total Dissolved __ Sulfates __ Manganese __ TCLP-Herbicides Solids, Total Volatile __ Surfactants __ Mercury _ TCLP-Volatiles I Other:_________________ __ UV254 __ Molybdenum _ TCLP-BNA’s _ Nickel

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