Chain of Custody Record, Sample AE03503, Feb 2002

NYC 9/11 Public Portal Document •f

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM hester ;Xovcom WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 N' ■< ' ■ nTMFn 1X

NYS-ELAP No. 10108 Time/Date Set: Form A-70 (rev. 10/01) I SarnpletTy^e (circle one): .1

Potable Treated Bottle #’s: 2. Non Potable 4. Other Chain of Custody?___ Yes No i

Time/Date Collected: .. . ' J — Comments: Collected By: ' i Agency Code: PWS #: Source ID: Type Descriptor: Collected From: Bill to: I Location’s/lndividual's Name i’"- Name/Company Street I. H _£LrLV£_ street_______ City/St/Zip City/St/Zip Identification of Source Phone#: Fax#: Collection Point fI) CA,CH, Bl? Check#: Amounts

BACTERIOLOGICAL ANALYSIS Lab#: Lab#: _ ______________________ ORGANIC POTABLE ANALYSIS ORGANIC NON POTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count (hemodialysis & all others) __ Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) __ Coliform P/A (Public supplies) ^.Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform MPN (priv well, raw, stp) 2<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 (SM18/663'0,8151) _ 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) >S^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 2Y-Antimony _S.Selenium _ pH __ Bromide XArsenic Silver __ Conductivity __ Bromate/Chlorate/Chlorite Y Barium __ Sodium •' __ Corrosivity (temp: .’C) __ Chloride 2>^Beryllium j£^Thallium . BOD (5 day) __ Cyanide __ Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride 2i,Cadmium Zinc , /. . _ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOa __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca+2 cIb __ Dissolved Oxygen __ Nitrogen, Nitrate as N V Chromium, Total _ Metals/CN __ 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 XCopper __ Solids, Settleable __ Phenol Iron TCLE __ 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 X Mercury _ TCLP-Volatiles Other: ________ _ UV254 5 Molybdenum _ TCLP-BNA’s X Nickel

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