Chain of Custody Record, Sample AE03822, 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 (914)231-1620 Fax (914) 231-1772 /MGS’.' I- fime/Date Set: ■ -■ S" f ■f ■ NYS-ELAP No. 10108 Form A-70 (rev. 10/01) I ‘

t[ I: Saipple Type (circle one): (^Potable

2. Non'Potable 3. Non Potable Treated

4. Other________________ ;_______ Bottle #’s: ^^7// ..

Chain of Custody? • _ Yes__ _ No 11

Time/Date' Collected: Comments; J K' Collected By: -I Agency Code:: . PWS #: ' Source ID:" ' Type Descriptor: Collected From: : , Bill to: Location’s/lndividual’s Name . . Name/Company 1 ■; street,_______ Street________ _ T

City/St/Zip_______________ City/St/Zip < ' Identification of Source Phone#:' Fax#: Collection Point. CA,CH, Bl? : Check#: Amounts.^1

I i ■ J. ■ ■

BACTERIOLOGICAL ANALYSIS ' Lab#: /-> <3 Lab#: ' L"* ■■= ... t ORGANIC POTABLE ANALYSIS X' > ORGANIC NONPOTABLE/SOLID ANALYSIS^ i __ Heterotrophic Plate Count" __ frihalomethanes (524) ' _ a Purgeable'Halocarbons ’(624/8260) “ % ''' ‘ J •. -(hemodialysis & all others) __ Volatile Halocarbons (524) Purgeable Aromatics''(624/8260) __ Coliform P/A (Public supplies)

s. _ : Coliform MPN '(phv well, raw, stp) _ ; Volatile Aromatics (524) , _ Acrolein & Acrylonitrile (8260) . . 7^' __ Total Trihaibmethane Potential (510) Org'an'ochlorine Pesticides’ (608/8081) ^^4 ■<

Fecal Coliform (all samples) __ Microextractables (504) ■ • _ .PCB's (Arochlors) -(OOS^OSI) ,Y '"jW Microscopic ’ Macroscopic __ Pesticides/PCB screen (508) _i Herbicides (SMl 8/6630,8151) L "M b- MAPI' - - Other; _i_________________ ' __ PCB.as Decachlorobiphenyl (508A) __ Herbicides (515) ' Other Pesticides,'(SMIS/BOSO) ' " .. ‘M 1 - __ [petroleum Hydrocarbon Scah -(310-13) "i __ Pesticides (525) Glycols in Water’ 7 \ M I Refrigerated?yes___ no __ Carbamate Pesticides* (531) '"M Acid Extractables (625/8270) >' ■•* -Ji'

I Chlorinated:? Fre'e'Chlorine Res:. yes_ no /mg/L __ Glyphosate (547) __ Diquat (549) __ Base Neutral Extractables (625/8270) _ i^'GC/MS Unknown Scan __ Chlorination Disinfection Byproducts (551)' ‘ _J. Phthalates (606MS);. ’-<’Y .• 7- ■3

Ik, Total Chlorine Res: . nng/L __ Haloacetic Acids (552) ■' Other::^

, RADIOCHEMICAL ANALYSIS _Other.Pesticides (SM18/6630) _ UCMR List 1 _;MtBE Only (524) i *■ ' ' I iLRadon _L.'Other/^:^

s- -INORGANIC ANALYSIS REQUESTED - Lab#: tv J"-

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I Color.- J'Li Turbidity M'pH.... ■■ ‘ Jr' Conductivity .. .• ' J’ . Acidity _ Alkalinity , “_ Bromide '* 1. __ ; Bromate/Chlorate/Chlorite _jAluminum “"Antimony' j:;! Arsenic ^iTBarium . .'^ Potassium-/. Seleriurrt ^SilverL f’’_C Sodiurn i .. f ‘ ‘

J Corrosivity (temp:_____ °C) vx; BOD_(5 day): __ Chloride"-.. . _ Cyanide'; f '" , Ji'Beryllium __ Boron" K. ■YYThallium J-'M' '• ' ' * Vanadium 7 ' ' JY', Carb’onaceous'BOD (5 day) _ Fluoride . Cadmium ‘ :xL'Zinc *- 'L ■ •' 1

f _ Soluble BOD (5.day)* M /Chemical Oxygen Demand 'M Dissolved Oxygen __ Hardness,’Total as CaCOa , _L,Nitrogen, Ammonia as N __ Nitrogen, Nitrate as N' __ Calcium, as CaCOa ‘ __ Calcium, Ca*2 ■ ~ «YChromium, Total ■clT;^ “ _'Metals/CN _.Volatiles ■ 7

.7- ' I LTSolal Organic Carbon __ ■ Nitrogen,’Nitrite as N __ Chromium, Hexavalent , -_ ^i-Total Organic Halides •_£' Solids, Percent (%) • Nitrogen, Total Kjeldahl as N ^Cobalt. x_ Semi-violatiles _Pesticides/PCB’s i ^iOil and Grease Xi-Copper _ Solids, Settleable ‘ __ Phenol L-lron - ’KLE, 'L- _ Solids, Suspended __ Phosphorus Total as P ^- Lead \ . IM. 4h . _TCLP-Metals ; p '2_ Solids, Total , __ Phosphorus, Ortho as P _ ; Magnesium' ’

r ■_2.TCLP-Pesticides . •x_ Solids, Total Dissolved . _ Sulfates, Manganese 1_TCLP-Herbicides ' __ Solids, Total Volatile -- ___Surfactants -"Mercury ■ xS Other; .^.i. - ■ = _ TCLP-Volatiles _ UV254 “ • .rl Molybdenum 2_ TCLP-BNAs ■ /■ xY Nickel .. ' ' 'u t3&.. j?

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