Chain of Custody Record, Sample AE03611, Feb 2002

NYC 9/11 Public Portal Document

I ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM i-\\fe.stdiester WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 f (914)231-1620 Fax (914) 231-1772 iJLI NYS-ELAP No. 1^108 j Time/Date Set: Form A-70 (rev. 10/01) I / Sample Type (circle one): ^1.‘Potable Bottle #'s: 3. Non Potable Treated F “‘2. Non Potable 4. Other_____________ Chain of Custody? Yes No Time/Date Collected: Comments: Collected By: Agency Code: PWS #:_________ Source ID: Type Descriptor: Collected From: Bill to: Location’s/lndividual’s Name Name/Company Street_______ ‘____________ Street__________ City/St/Zip________________ Citv/St/Zio Identification of Source Phone#:________ Fax#: Collection Point ... / CA,CH, Bl? Check#: Amounts

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:_________ __________ __ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS, __ Heterotrophic Plate Count __ Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) I (hemodialysis & all others) __ 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) fl __ Microscopic __ Microextractables (504) __ PCB’s (Arochlors) (608/8081) is-- __ Macroscopic __ Pesticides/PCB screen (508) _ Herbicides (SM18/6630,8151) • _ API __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides »(SM18/6630) t ;.-, __ 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 _L Haloacetic Acids (552) __ Other:_______________________________ Other Pesticides (SMI8/6630) pH _____________ _UCMRList 1 RADIOCHEMICAL ANALYSIS _MtBEOnly (524) __ .Radon •ft r! __ Other_______________________ z ■ t, INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ /Acidity __ Aluminum __ Potassium __ Turbidity __ Alkalinity __ Antimony Selenium _ pH __ Bromide __ Arsenic _i'Silver 4 __ Conductivity __ Corrosivity (temp:. °C) __ Bromate/Chlorate/Chlorite __ Chloride __ Barium __ Beryllium < _ Sodium __ Thallium _ BOD (5 day) __ Cyanide __ Boron __ Vanadium f __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium t __ Zinc _ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOa CLP __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca-^’ _ Metals/CN __ 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

1 __ Solids, Percent (%) __ Solids, Settleable __ Solids, Suspended __ Oil and Grease __ Phenol __ Phosphorus Total as P __ Copper __ Iron __ Pesticides/PCB’s

tc_lp __ Lead _TCLP-Metals __ Solids, Total __ Phosphorus, Ortho as P __ Magnesium __ TCLP-Pesticides __ Solids, Total Dissolved _ Sulfates __ Manganese F' __ Solids, Total Volatile __ Surfactants __ Mercury __ TCLP-Herbicides _ TCLP-Volatiles .'’-■-Other: ■_______ ____________ _ UV254 ■ Molybdenum t _ TCLP-BNA’s __ Nickel

NYC-WTC_000073778