Chain of Custody Record, Sample AE03917, Feb 2002

NYC 9/11 Public Portal Document ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ,0

ISS™ WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 j/ri HL *

NYS-ELAP No. l'01O8 Time/Date Set; Form A-70 (rev. 10/01)

imple Type (circle one): j^otable . 3. Non Potable Treated Bottle #'s: 2. Non Potable 4. Other____________ Chain of Custody?___ Yes___ Mo Time/Date Collected: 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 _ CA,CH, Bl? Check#:. Amounts

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:_______________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count _YTrihalomethanes (524) (hemodialysis & all others) __ Purgeable Halocarbons (624/8260) t^olatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) _l/wlatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) p; __ 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 (SM18/6630) __ Other:_____________________ __ Herbicides (515) __ Petroleum'Hydrocarbon Scan (310-13) __ Pesticides (525) __ Glycols in Water Refrigerated?yes no __ Carbamate Pesticides (531) _ Acid Extractables (625/8270) 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) r-.;. Total Chlorine Res:mg/L __ Haloacetic Acids (552) __ Other:_J____________________ __ _Other Pesticides (SM18/6630) pH ___________ __ UCMR List 1 RADIOCHEMICAL ANALYSIS _MtBE Only (524) __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: or.’ __ Color __ Acidity __ Aluminum __ Potassiurr -< c;- __ Turbidity __ Alkalinity __ Antimony __ Selenium _ pH __ Bromide __ Arsenic __ Silver ‘ __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium Corrosivity (temp: °C) __ Chloride __ Beryllium _ Thallium i _ BOD (5 day) __ Cyanide __ Boron __ Vanadiumi __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Zinc _ Soluble BOD (5 day) __ Hardness. Total as CaCOa __ Calcium, as CaCOa __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*2 CLP __ Dissolved Oxygen _ Metals/CN __ Nitrogen, Nitrate as N __ Chromium, Total __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Volatiles __ Chromium, Hexavalent ( __ Nitrogen, Total Kjeldahl as N __ Semi-violatiles __ Total Organic Halides __ Cobalt __ Pesticides/PCB's __ Solids, Percent (%) __ Oil and Grease __ Copper __ Solids, Settleable __ Phenol __ Iron TCLP __ Solids, Suspended __ Phosphorus Total as P __ Lead __ Phosphorus, Ortho as P __ TCLP-Wetals __ Solids, Total __ Magnesium __ TCLP- Pesticides __ Solids, Total Dissolved __ Sulfates __ Manganese __ TCLP-Herbicides __ Solids, Total Volatile __ Surfactants __ Mercury _ TCLP-Volatiles __ Other;_________________ _ UV254 __ Molybdenum TCLP-BNA's __ Nickel ----------- T

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