Chain of Custody Record, Sample AE03917, Feb 2002

NYC 9/11 Public Portal Document environmental SERViCES SAMPLE SUBMISSION FORM

WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 */' 4

(914).231-1620 Fax (914) 231-1772 NYS-ELAP No. ldl08 Time/Date Set: Form A-70 (rev.10/01)

l^mple Type (circle one): I Bottle #'s. AA/t # I 1y Potable . 3. Nori Potable Treated 2. Non Potable 4. Other Chain of Custody?___ Yes___ No Time/Date Collected; /f - 3 Comments; Collected By:___________________ Agency Code: PWS #:_______ Source ID: Type Descriptor: Collected From; Bill to; Location’s/lndividual’s Name Name/Company Street _ _______________________ Street_______ City/St/Zip_____________________ City/St/Zip Identification of Source Phone#: Fax#: Collection Point _ 3 CA,CH, Bl? Check#: Amounts

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:_______________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic. Plate Count J^rihalomethanes (524) (hemodialysis & all others) __ Purgeable Halocarbons (624/8260) ty^Qlatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) _5^latile Aromatics (524) __ Coliform MPN (priv well, raw, stp) __ 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 (SMI 8/6630) __ Other;____________________ _ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) __ Pesticides (525) __ Glycols in Water “5, Refrigerated?yes___ no __ ^Carbamate Pesticides (531) _ Acid Extractables, (625/8270) cc Chlorinated:? yes no __ Glyphosate (547) __ Base Neutral Extractables (625/8270) ~ __ Diquat (549) __ GC/MS Unknown Scan Free Chlorine Res:mg/L __ Chlorination Disinfection Byproducts (551) __ Phthalates (606MS) Total Chlorine Res:mg/L __ Haloacetic Acids (552) J __ Other:1. __ Other Pesticides (SMI8/6630) pH ___________ __ UCMR List 1 RADIOCHEMICAL ANALYSIS _MtBE Only (524) __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: __ .Color __ Acidity __ Aluminum __ Potassium __ Turbidity __ Alkalinity __ Antimony __ Seleniurri' _ pH __ Bromide __ Arsenic __ Silver j __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium j __ Corrosivity (temp:. °C) __ Chloride __ Beryllium ’ __ Thalliumj O- _ BOD (5 day) __ Cyanide __ Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride _ Cadmium __ Zinc i _ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOs __ Calcium, Ca'"^ CLP __ Chemical Oxygen Demand __ Nitrogen. Ammonia as N __ Dissolved Oxygen __ Nitrogen, Nitrate as N _ Metals/CN __ 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 __ Solids, Settleable __ Phenol __ Iron TCLP __ Solids, Suspended __ Phosphorus Total as P __ Lead __ TCLP-Netals __ Solids, Total __ Phosphorus. Ortho as P __ Magnesium __ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates __ Manganese I __ T CLP-Perbicides __ Solids, Total Volatile __ Surfactants __ Mercury __ TCLP-Volatiles __ Other; _ _______________ _ UV254 __ Molybdenum I _ TCLP-BNA's __ Nickel 1

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