Chain of Custody Record, Sample AE03914, Feb 2002

NYC 9/11 Public Portal Document i?: ‘ A Y;- 'a Y- \ ri "..4 ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ‘ WESTCHESTER COUNTY LABORATORIES AND RESEARCH " ■' . ' 2 Dana Road, Valhalla, New York'10595 ' ’ t (914) 231-1620 Fax (914) 231-1772 '/Y ./Y' , .NYS-ELAP'No.?ld.'108 1

IF • Time/Date Set: ’'if;'-? Form A-70'(rev. 10/01)' r

Sample Type - (circle one):

I' ■tJ ./Potable 2. Non Potable 3. Non Potable Treated 4. Other .. Bottle #’s: Chain of Custody? // M—"No ? 1 pme/Date Collected:________ . Comments: ' V'?

Collected By; g<’ z.-lYWyTT’ PWS #: >' Agency Code: < Source ID: iType Descriptor: h- Collected Frorh: , Bill to:

I • Location’s/lndividual’s Name'_i/2_ .'('-•‘Name/Company g. -a’, vS

Street H :-------- ——— 1 City/St/Zip£ Citv/St/Zio ' •' . ’’r Ideritification of Source Phone#:______ /Fax#:

?- - Collection Point ■1 ' ; rCA,CH, Bl? Check#: Y''/" - ■.i*’ ,f.. ,s.. ■;?/, Amounts Y . Y.-. a: ;-- ■ .j,. j,,/

' /. 'Y/r''A.-l: '■'!/< . 'f t.- i . J -.-s;''' ■’ BACTERIOLOGICAL ANALYSIS Lab#: __________ ___ T,’'-' 7. S , ■'/ /Yr Y"' "'i ' ' '-i ' ■' » ■ ; Lab#: . ‘ -_____________X t Heterotrophic Plate Count ' ORGANIC POTABLE ANALYSIS . YORGANIC NONPO-TABLE/SOLID ANALYSIS, /

f J (hemodialysis & all others) _1 Coliform P/A (Public supplies) __ Trihalomethanesr (524) __ Volatile Halocarbons (524) ' ^S^^UrgeableHalorarbons (624/8260) - '7^ 'BJRurgeable%6matics;'^(624/8260)f/;:4

fe -1 Coliform MPN (priv well, raw, stp) _j Fecal Coliform (all samples) _F Microscopic __ Volatile Aromatics (524) _Total'trihalomethane Potential (510) __ Microextractables (504) __ Pesticides/PCB screen (508) .yJ/Y.Acrolein ’&’Acrylohitrile' .(8260) 'Y / & J* ':' Ji''Ofgahochl6nne‘Pesticides (608/8081)^1 lifei^PCB's: (Arochlors) 4608/8081)^ / ‘Y .1 .Y//J<Herbicides'(SMl8/6630,815i) / ” . ‘irr: I .t f

L Macroscopic 6. _± API __ PCB as Decachlorobiphenyl (508A) __ Herbicides'(515) '' 'JL-'Other Pesticides tSM 18/6630) - ’ vf 1 l^^ '^troleurn Hydrocarbon ^Scarf- i[31(Kt3)’5;^.

I -r- Other: ■ -- Refrigerated?t yes i. no ' __ Pesticides (525) J_ Carbarhate Pesticides (531) 3^SG^c8ls’'ih Water--%< ,'Y'YY?:./Y" /f ? ,V:S2y>kcid’^'(aables>'(62^te^^ ,1

Is" Chlorinated:? ' yes___ no Free Chloririe Res:t_______ _ mg/L Total Chlorine Res:________ mg/L __ Glyphosate (547) _ Diquat (549) __ Chlorination Disinfection Byproducts' (551) __ Haloacetic Acids (552) ' -Aljj^^BaM jMeu^r^EJ^ctables ;(625/8270)-'o% i 'Y./;./GC/MS'Unknown.Scan'/.;.- 'cC- J I

__ Other.Pesticides (SMI8/6630) , ■A ( ■/-♦ pH _________ - _ UCMR List 1‘ - , I RADIOCHEMICAL ANALYSIS _ MtBE Only (524) ___ iRadon '’ - ' ■ .rr.rr.-/Ya.-.., ... i " 7 _‘Otlier ? ,.£ * '/C. Y/.,, -J' J- a?

r /t. ’X-s INORGANIC ANALYSIS REQUESTED -^Lab#: f J r'" -’"ts-. ..J' /£ Color' ‘ _ Acidity'f ... Aluminum SJ;// -A-l Potassium ; ’, V a . Jit Turbidity , ’- ", •* Alkalinity; _:;/Antimony . A’-/ ' LzSeleniuni A;--. AK "•cL' pH.- -__.Bromicle'-UY ‘- ■/JArsenic?; t;, 'j . ' - Y/^Silver --fi';;? s V* Conductivity __ 'Bromate/Chlorate/Chlorite <, Barium ' ■/-’'./v,., __ iSoditml.J , -iyYf ,.''-

K; V- Corrosivity (temp: ' _L BOD (5 day)- °C) _ Chloride , Cyanide ’ , " ^j'Befyllium /--YJ J, __ Boron '• J/U'/!’’ V- ' jjThaHiunT j'- •p -’' . i-Vahadium ' J -v y •• ’ 1 .J_ Carbonaceous BOD (5 day) __ Fluoride , __ Cadmium r - ■7>''Zinc \ ./. Soluble BOD (5 day) ■__ Hardness, total asCaCOs , __ Calcium, as CaCOa.: -',

i J_ Chemical Oxygen Demand _ Nitrogen, Ammonia as'N ' CLP'.. __ Calcium, Ca+^.C _/>Chromium, Totally,/, * ' _Melals/CN _j_ Dissolved Oxygen __ Nitrogen,- Nitrate as N 'j_ Total Organic Carbon _L Total Organic Halides __ Nitrogen;-Nitrite as N __ Nitrogen, Total Kjeldahl as N .__ Chromium, Hexavalent • _<:rCobalt ■* .fS"' __ Volatiles/ Sem"i-violatiles‘ If' 2/ Solids, Percent (%)’ ZJ'Pesticides/PCB’s __ Oil and Grease jxCopper ■ a' Solids,' Settleable •__ Phenol ’ t^lron " V. TCLP’.

I , _ Solids, Suspended __ Phosphorus Total as P j>''Lead . yl^TCLPMMetals" - W -J ■

_L Solids, Total . __ Phosphorus, Ortho as P 1_ Magnesium a 1_SJCLR-Pesticides _L Solids, Total Dissolved __ Sulfates ' f _i_.'Manganese c > Solids, Total Volatile __ Surfactants , .--Mercury' *' _-TCLP-Herbicides /_ TCLP-Volatiles. -■Y'bther: ______________ _ UV254 ' ■ Molybdenum

r • __^-'Nickel' — TCLP-BNA’s - :/

j; -.-J 4

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