Chain of Custody Record, Sample AE03730, Feb 2002

NYC 9/11 Public Portal Document I I ,■:« ACCpa 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: Form A-70 (rev. 10/01)

Sample Type (circle one): f

1. Potable 3. Non Potable Treated Bottle #’s; ’ ‘ ' >________

2. Non Potable 4. Other.___________ Chain of Custody?___ Yes No Time/Date Collected: Comments: Collected By:____ L. Agency Code: PWS #:______ Source ID: Type Descriptor: Collected From: Bill to: Location’s/lndividual’s Name Name/Company r

Street__________ _______ Street_______ City/St/Zip______________ City/St/Zip Identification of Source Phone#: Fax#: Collection Point CA,CH, Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:_______________________ I ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS ■i __ Heterotrophic Plate Count __ Purgeable Halocarbons (624/8260) (hemodialysis & all others) __ Trihalomethanes (524) __ 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) • __ 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 Refrigerated?yes . no __ Carbamate Pesticides - (531) __ Acid Extractables (625/8270) • -ft

Chlorinated;? yes, no __ Glyphosate (547) __ Base Neutral Extractables (625/8270)

Free Chlorine Res: . mg/L __ Diquat (549) __ Chlorination Disinfection Byproducts (551) __ GC/MS Unknown Scan _ Phthalates (606MS) I Total Chlorine Res: . mg/L __ Haloacetic Acids (552) __ Other:____________________________ "’s:? __ Other Pesticides (SMI8/6630) pH ___________ __ UCMR List 1 RADIOCHEMICAL ANALYSIS _MtBEOnly (524) ■5^ __ Radon __ Other _ ___________________ 1

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Aridity __ Aluminum __ Potassium ; __ Turbidity __ Alkalinity __ Antimony __ Selenium • i I _ pH __ Bromide __ Arsenic __ Silver ' __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium __ Corrosivity (temp:. _ BOD (5 day) °C) __ Chloride __ Cyanide __ Beryllium __ Boron __ Thallium, __ Vanadium 9 __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Zinc Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOs CLP __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*2 __ Metals/CN .'g __ 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 __ Pesticides/PCB’s __ Solids, Percent (%) __ Oil and Grease __ Copper I __ Solids, Settleable __ Phenol __ Iron tclp __ Solids, Suspended __ Phosphorus Total as P __ Lead _TCLP-Metals ■■

__ Solids, Total __ Phosphorus, Ortho as P __ Magnesium __ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates __ Manganese _ Solids, Total Volatile __ Other:_________________ __ Surfactants _ UV254 __ Mercury __ TCLP-Herbicides _ TCLP-Volatiles 9 __ Molybdenum _ TCLP-BNA’s J __ Nickel ( NYC-WTC_000073808