Chain of Custody Record, Sample AE03503, Feb 2002

NYC 9/11 Public Portal Document ■^5

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM hester I ^ivcom WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 o/ ■ < I B ■WWTl I A 1 -* 11 NYS-ELAP No. 10108 Time/Date Set; Form A-70 (rev. 10/01) P P Sample Type (circle one): O G 299 3 (^Potable 3. Non Potable Treated Bottle #'s: - /5'OZ. IZ ZtL / <1 2 'X Q 2. Non Potable 4. Other Chain of Custody? Yes___ No 1 Time/Date Collected: Comments: Collected By: L . Agency Code: PWS #:________ Source ID: Type Descriptor: Collected From: Bill to: Location’s/lndividual’s Name 70 VC _ Name/Company Street . dC______________ Street_________ City/St/Zip _ My I o s 9s Citv/St/Zio Identification of Source Phone#:_______ Fax#: 1 Collection Point. rtcj un I CA,CH, Bl? Check#: Amounts

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:_______________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/'SOLID ANALYSIS __ Heterotrophic Plate Count (hemodialysis & all others) __ Tfihalomethanes (524) __ Purgeable Halocarbons' (624/8260) __ Coliform P/A (Public supplies) L/yolatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform MPN (priv well, raw, stp) t/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 Decachlordbiphenyl (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) iSGC/MS Unknown Scan Free Chlorine Res:mg/L __ Chlorination Disinfection Byproducts (551) __ Phthalates (606MS) Total Chlorine Res:mg/L __ Haloacetic Acids (552) __ Other:_____________ i______________ __ Other Pesticides (SMI8/6630) pH ___________ _ UCMR List 1 RADIOCHEMICAL ANALYSIS _ MtBE Only (524) __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Aridity ■ T^^luminum _ Potassium . __ Turbidity __ Alkalinity j/Antimony _^^^lenium _ pH __ Bromide j/^senic _ii^ilver __ Conductivity __ Bromate/Chlorate/Chlorite _k<Barium _ Sodium __ Corrosivity (temp: °C) __ Chloride je^eryllium _i^jThallium _ BOD (5 day) __ Cyanide __ Boron __ ^nadium __ Carbonaceous BOD (5 day) __ Fluoride jXtadmium 3<^inc _ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOs __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N ;alcium, Ca*’ CLE __ Dissolved Oxygen __ Nitrogen, Nitrate as N _ Metals/CN ihromium, Total __ Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N hromium. Hexavalent __ Semi-violatiles __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N obalt __ Pesticides/PCB's __ Solids, Percent (%) __ Oil and Grease . opper __ Solids, Settleable __ Phenol ‘^ron TCLP __ Solids, Suspended __ Phosphorus Total as P JCLead _TCLP-Metals __ Solids. Total __ Phosphorus, Ortho as P _ Magnesium __ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates __ TCLP-Herbicides _^olids, Totel Volatile __ Surfactants _ TCLP-Volatiles ±1 Other: CS___________ UV254 ✓^lybdenum .±(5lickel _ TCLP-BNA's

NYC-WTC_000073739