Chain of Custody Record, Sample AE03503, Feb 2002

NYC 9/11 Public Portal Document

^Wl ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM vs WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 “ /1 < IJi Kt* I Hl Iba IX NYS-ELAP No. 10108 Time/Date Set: P- Form A-70 (rev. 10/01)

Sample Type (circle one): <5Bottle #’s: Qj- i/■ iZ- ( ftp (^Potable 3. Non Potable Treated 2. Non Potable 4. Other____________ Chain of Custody?Yes___ No 18 / ’ Time/Date Collected: :> -1 Vo? Comments: Collected By: L. VtJoGO 9 / Agency Code: PWS #:______ Source ID: Type Descriptor: Collected From: Bill to: Location’s/lndividual’s Name K) C 7^ P P Name/Company Street 19 'br‘> \Jg Street________ City/svzip v/o.l ha Ua . py inrQV’ City/St/Zip Identification of Source________________________ Phone#: Fax#: Collection Point. pp I 1ft_________ 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^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 (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) jZ 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 ___________ _UCMRList1 RADIOCHEMICAL ANALYSIS _ MtBE Only (524) __ Radon _ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: A __ Color __ /k:idity '■ i;^^luminum __ Potassium __ Turbidity __ Alkalinity ^y%ntimonv ii^elenium _ pH __ Bromide «z^rsenic jYsilver __ Conductivity __ Bromate/Chlorate/Chlorite 7 Barium __ Sodium ’ __ Corrosivity (temp:, .°C) __ Chloride tZfeervIlium xZ”Thallium / _ BOD (5 day) __ Cyanide __ Boron Vanadium ■ __ Carbonaceous BOD (5 day) __ Fluoride _^^admium iZ^Zinc \ _ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOs CLP ; \ __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N Calcium. Ca'"^ __ Dissolved Oxygen ^Chromium, Total _ Metals/CN ' __ Nitrogen, Nitrate as N __ Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Total Organic Halides uztobalt __ Semi-violatiles __ Nitrogen, Total Kjeldahl as N __ Solids, Percent (%) 4?t;opper __ Pesticides/PCB’s __ Oil and Grease __ Solids, Settleable __ Phenol 4^ron __ Solids, Suspended __ Phosphorus Total as P tclp *<Lead __ Solids, Total _TCLP-Metals __ Phosphorus, Ortho as P __ ^Magnesium __ Solids, Total Dissolved lY^anganese __ TCLP-Pesticides __ Sulfates Solids, Total Volatile t^^ercurv __ TCLP-Herbicides __ Surfactants Other: _________ .i^'Molybdenum _ TCLP-Volatiles _ UV254 _ TCLP-BNA’s 4yfjickel

NYC-Wfc_C)00073'738