Chain of Custody Record, Sample AE03611, Feb 2002

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM JJwestchester gg^gpvcom WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 £

(914)231-1620 Fax (914) 231-1772 NYS-ELAP No.’10108 Time/Date Set; Form A-70 (rev. 10/01) ,

Sample Type (circle one): 1. Potable 3. Non Potable Treated Bottle #’s: f 2?Non Potable 4. Other____________ Chain of Custody? I Yes___ No ; Time/Date Collected: Comments: Collected By;L Agency Code; /t /. ■ a PWS #:________ Source ID: Type Descriptor; I Collected From: Bill to: * Location’s/lndividual’s Name / / z.. Name/Company Street_________________ Street_________ I City/St/Zip______________ City/St/Zip I Identification of Source Phone#:_______ Fax#; Collection Point CA,CH, Bl? Check#: Amounts

BACTERIOLOGICAL ANALYSIS Lab#: " -Z / / 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) __ 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 (SMI8/6630) I 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) I pH ___________ _UCMR List 1 RADIOCHEMICAL ANALYSIS _MtBE Only (524) _ i_ Radon ‘ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: ' Color __ Acidity __ Aluminum __ Potassium __ Turbidity __ Alkalinity __ Antimony __ Selenium — pH __ Bromide __ Arsenic __ Silver _!_ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium « Corrosivity (temp: “C) __ Chloride __ Beryllium __ Thallium _ BOD (5 day) _1 Cyanide __ Boron __ Vanadium J_ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Zinc *• Soluble BOD (5 day) __ Hardness,-Total as CaCOs __ Calcium, as CaCOs ' Chemical Oxygen Demand CLP __ Nitrogen, Ammonia as N __ Calcium, Ca*2 • ’ Dissolved Oxygen - Nitrogen, Nitrate as N _ Metals/CN __ Chromium, Total _L Total Organic Carbon __ Volatiles __ Nitrogen, Nitrite as N __ Chromium, Hexavalent 21_ Total Organic Halides __ Semi-violatiles __ Nitrogen, Total Kjeldahl as N __ Cobalt __ Solids, Percent (%) __ Pesticides/PCB's __ Oil and Grease __ Copper 1 Solids, Settleable __ Phenol __ Iron J_ Solids, Suspended TCLP __ Phosphorus Total as P __ Lead __ Solids, Total __ TCLP-Metals __ Phosphorus, Ortho as P __ Magnesium _ Solids, Total Dissolved __ TCLP-Pesticides __ Sulfates __ Manganese . Solids, Total Volatile _TCLP-Herbicides __ Surfactants __ Mercury * Other:_________________ __ TCLP-Yolat! les _ UV254 __ Molybdenum ■ i _ TCLP-BNA’s __ Nickel

............................ .................................... NYC-WTC_000073776