Chain of Custody Record, Sample AE03730, Feb 2002

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH 'I 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 NYS-ELAP No. 10108 I Time/Date Set; Form A-70 (rev. 10/01)

Sample Type (circle one); . 1. Potable 3. Non Potable Treated Bottle #’s:

f f 2. Non Potable 4. Other___________ Chain of Custody? Yes___ No Time/Date Collected; >■- / Comments: f PWS #:________ Source ID: Type Descriptor: Collected By: > ■' Agency Code: ! Collected From: Bill to; 4 Location’s/lndividual's Name Name/Company _ Street_________________ Street_________ City/SVZip______________ 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 __ Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) (hemodialysis & all others) __ Coliform P/A (Public supplies) __ Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) I __ Coliform MPN (priv well, raw, stp) __ Volatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) ‘ -ft

__ 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) _ Other:____________ ________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) __ Pesticides (525) __ Glycols in Water J Refrigerated?yes no __ Carbamate Pesticides (531) __ Acid Extractables (625/8270) , Chlorinated:? yes no __ Glyphosate (547) __ Base Neutral Extractables (625/8270) __ Diquat (549) j^ '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 (SM18/6630) *3^ pH ___________ __ UCMRListI RADIOCHEMICAL ANALYSIS _ MtBE Only (524) __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color ■__ /Viidity __ Aluminum __ Potassium ■I __ Turbidity __ Alkalinity _ Antimony _ ; Selenium ' . _ pH __ Bromide _ .-Arsenic _.Silver ' ' ■ __ Conductivity __ Bromate/Chlorate/Chlorite Barium __ Sodium °C) a __ Corrosivity (temp:. __ Chloride ^■Beryllium _iThallium 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 CLE~ __ Chemical Oxygen Demand __ Dissolved Oxygen __ Total Organic Carbon __ Nitrogen, Ammonia as N __ Nitrogen, Nitrate as N __ Nitrogen, Nitrite as N __ Calcium, Ca*2 _ iChromium, Total > __ Chromium, Hexavalent _ Metals/CN __ Volatiles 1 __ Semi-violatiles __ Total Organic Halides __ Solids, Percent (%)' __ Nitrogen, Total Kjeldahl as N __ Oil and Grease _ Cobalt __ Copper __ Pesticides/PCB’s 1 __ Solids, Settleable __ Phenol __ Iron TCLP ' __ Solids, Suspended __ Phosphorus Total as P —Lead _TCLP-Metals __ Solids, Total __ Phosphorus, Ortho as P _ Magnesium •1 __ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates __ Manganese __ TCLP-Herbicides __ Solids, Total Volatile __ Surfactants _ ; Mercury _ TCLP-Volatiles _ Other;_________________ _ UV254 __ Molybdenum _ TCLP-BNA’s 1 __ . Nickel

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