Chain of Custody Record, Sample AE03611, Feb 2002

NYC 9/11 Public Portal Document

ACCo ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595- (914)231-1620 Fax (914) 231-1772 ’ Time/Date Set: NYS-ELAP No. lftl08 Form^A-70 (rev.10/01)

Sample Type (circle one): «'1. Potable I3. Non Potable Treated Bottle #’s: '2. Non Potable 4. Other Chain of Custody?___ Yes No Time/Date Collected: Comments: Collected Bv: * ' f i- Agency Code: PWS #: Source ID: Type Descriptor: Collected From: Bill to: Location’s/lndividual's Name Name/Company Street_________________ Street_______ City/St/Zip ____________ City/St/Zip 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 (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 (SMI8/6630,8151) _ 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) _ i'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 __ Antimony __ Selenium _ pH __ Bromide __ Arsenic __ Silver __ Conductivity __ Bromate/Chlorate/Chlorite _i_Barium __ Sodium __ Corrosivity (temp:. .°C) __ Chloride _ Beryllium __ Thallium _ BOD (5 day) __ Cyanide __ Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium .uL'Zinc _ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOs __ Chemical Oxygen Demand CLP __ Nitrogen, Ammonia as N __ Calcium, Ca*2 __ Dissolved Oxygen __ Nitrogen, Nitrate as N _ Metals/CN _ iChromium, Total __ Total Organic Carbon __ Volatiles __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N __ Semi-violatiles __ Cobalt __ Solids, Percent (%) __ Pesticides/PCB’s __ Oil and Grease __ Copper __ Solids, Settleable __ Phenol _ Iron tclp __ Solids, Suspended __ Phosphorus Total as P __ Lead __ Solids, Total __ TCLP-Metals __ Phosphorus, Ortho as P __ Magnesium __ Solids, Total Dissolved __ TCLP-Pesticides __ Sulfates __ Manganese __ Solids, Total Volatile __ T CLP-Herbicides __ Surfactants __ Mercury __ Other: _________________ _ TCLP-Volatiles _ UV254 __ Molybdenum _ TCLP-BNA’s __ Nickel

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