Chain of Custody Record, Sample AE03730, Feb 2002

NYC 9/11 Public Portal Document 5

VH ACCft ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM 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: , ’> Y,____ Form A-70 (rev.10/01) h 5 '7 -1 x t 'OS, Sample Type (circle one): ■7 ?' <!/) Si x.l. Potable 3. Non Potable Treated Bottle #'s:_______________ 2. Non Potable 4. Other • t 1 Chain of Custody?__ _ Yes___ No jt Time/Date Collected: Comments: Collected By: U - Xa t L X Agency Code: PWS #:______ Source ID: Type Descriptor: Collected From: Bill to: Location's/lndividual’s Name Name/Company 1 Street_____________________ Street_______ City/St/Zip__________________ City/St/Zip Identification of Source Phone#: Fax#: Collection Point- CA,CH, Bl? Check#: Amounts r

BACTERIOLOGICAL ANALYSIS Lab#: i i •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) I /t. __ Coliform MPN (priv well, raw, stp) __ Volatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) __ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081) __ Microextractables (504) _ PCB’s (Arochlors) (608/8081) 1 __ Microscopic . Pesticides/PCB screen (508) _ Herbicides (SMI8/6630,8151) I .Vfi“ __ Macroscopic _ API __ PCB as Decachlorobiphenyl (508A) _ _ Other Pesticides (SM18/6630) 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

t Total Chlorine Res: - mg/L __ Chlorination Disinfection Byproducts (551) __ Haloacetic Acids (552) _ Other Pesticides (SMI8/6630) _ Phthalates (606MS) __ Other:__________________________ 4 pH ___________ __ UCMR List 1 RADIOCHEMICAL ANALYSIS _MtBE Only (524) __ Radon __ Other____________________ I INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ /Acidity ^^/Aluminum __ Potassium __ Turbidity _ pH __ Conductivity __ Corrosivity (temp:. °C) __ Alkalinity __ Bromide __ Bromate/Chlorate/Chlorite __ Chloride z-' Antimony . Z Arsenic Barium j_^Beryllium 2r:.'Selenium Silver __ Sodium .^"Thallium I _ BOD (5 day) __ Cyanide __ Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium ___ .'Zinc __ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOa "CLP I __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca+2 __ Dissolved Oxygen _ Metals/CN 4 __ 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 V'-^Cobalt __ Solids, Percent (%) __ Solids, Settleable __ Oil and Grease __ Phenol '"popper "■^fron __ Pesticides/PCB’s *

TCLP J __ Solids, Suspended __ Phosphorus Total as P Lead __ TCLP-Metals __ Solids, Total __ Phosphorus, Ortho as P __ Magnesium ■i __ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates Ji:.'Manganese __ TCLP-Herbicides __ Solids, Total Volatile __ Surfactants jj Mercury other: X V*— __ TCLP-Volatiles _ UV254 Molybdenum _ TCLP-BNA’s __ .-Nickel

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