Chain of Custody Record, Sample AE03611, Feb 2002

NYC 9/11 Public Portal Document I

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana' Road, Valhalla, New York 10595 o //If ■ (914) 231-1620 Fax (914) 231-1772 I NYS-ELAP No. 10'l08 Time/Date Set: Form A-70 (rev. 10/01) I ■•K J - ). .-f- >(..• I f' sf'i Sample Type (circle one): (l, Potable 3. Non Potable Treated Bottle #'s:' f \ A -! ( 2. Non Potable 4. Other___________ Chain of Custody? Yes No I. ( . ! Time/Date Collected: Comments: Collected By: I- t Agency Code: PWS #:________ Source ID: Type Descriptor: I

:.l Collected From: Bill to: Location’s/lndividual's Name Name/Company Street_________________ Street_________ • 1 City/St/Zip______________ City/St/Zip , Identification of Source Phone#:_______ Fax#: Collection Point // / ? X CA,CH, Bl? Check#: Amounts. ' I

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:_______________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count __ Trihalomethanes (524) (hemodialysis & all others) __ Purgeable Halocarbons (624/8260) __ Coliform P/A (Public supplies) __ Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) ■r __ Coliform MPN (priv well, raw, stp) __ Volatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) £ __ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081)

I __ Microscopic __ Macroscopic __ Microextractables (504) __ Pesticides/PCB screen (508) __ PCB as Decachlorobiphenyl (508A) _ PCB’s (Arochlors) (608/8081) __ Herbicides (SM18/6630,8151) _ API __ 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) XAGC/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 (SM18/6630) pH __ _________ _UCMR List 1 RADIOCHEMICAL ANALYSIS _ MtBE Only (524) . __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: / •__ Color __ Acidity Aluminum __ Potassium __ Turbidity __ Alkalinity - .Z Antimony ^Selenium pH __ Bromide ■ Arsenic 2L.''Silver __ Conductivity __ Bromate/Chlorate/Chlorite _i:Barium __ Sodium r:- Corrosivity (temp: “C) __ Chloride Beryllium ^Thallium _ BOD (5 day) __ Cyanide __ Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride Cadmium YZinc _ Soluble BOD (5 day) __ Hardness, Total as CaCOa - Calcium, as CaCOs CLP 5 __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*2 __ Dissolved Oxygen __ Nitrogen, Nitrate as N _Metals/CN \Yt:hromium, Total __ Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Semi-violatiles __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N _-Cobalt __ Solids, Percent (%) __ Pesticides/PCB’s __ Oil and Grease ■■■> Copper ___ Solids, Settleable __ Phenol Iron TCLP __ Solids, Suspended __ Phosphorus Total as P rl Lead _TCLP-Metals __ Solids, Total __ Phosphorus, Ortho as P __ Magnesium __ ‘Solids, Total Dissolved __ TCLP-Pesticides __ Sulfates _zManganese __ zSolids, Total Volatile_ __ TCLP-Herbicides __ Surfactants __^Mercury Other:________ _ TCLP-Volatiles _ UV254 __ Molybdenum _ TCLP-BNA's __ -Nickel

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