Chain of Custody Record, Sample AE03917, Feb 2002

NYC 9/11 Public Portal Document ACCn ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914) 231-1620 Fax (914) 231-1772 ' lJ NYS-ELAP No.JGiOS Time/Date Set: Form A-70 (rev3o/O1)

^mple Type (circle one): f 1Jpotable 3. Non Potable Treated Bottle #’s: fl if 2. Non Potable 4. Other Chain of Custody? Yes___ Mo Time/Date Collected: (0 Comments: Collected By: Agency Code: PWS #:_________ Source ID: Type Descriptor: 'S Collected From: Bill to: r--: 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#: AmpuntS i -4----- 2 BACTERIOLOGICAL ANALYSIS Lab#: I - Lab#:___________________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count □Arihalomethanes (524) __ Purgeable Halocarbons (624)8260) (hemodialysis & all others) ^"^latile Halocarbons (524) __ Coliform P/A (Public supplies) __ Purgeable Aromatics (624/8260) Ji^olatile Aromatics (524) __ Coliform MPN (priv well, raw, stp) __ Acrolein & Acrylonitrile (8260) , __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (668/8081) g __ Fecal Coliform (all samples) __ Microscopic _ Microextractables (504) __ PCB’s (Arochlors) (608/8081)' __ Macroscopic __ Pesticides/PCB screen (508) _ Herbicides (SM18/6630,8151) __ PCB as Decachlorobiphenyl (508A) co _ API __ Other Pesticides (SMI 8/6630) __ Other:________________________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13)_r) __ 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) - Total Chlorine Res:mg/L __ Haloacetic Acids (552) __ Other: ___________________________ __ Other Pesticides (SM18/6630) pH _____________ _UCMR List 1 RADIOCHEMICAL ANALYSIS _MtBE Only (524) ___ Radon __ Other______________________ _

INORGANIC ANALYSIS REQUESTED - Lab#: ‘co 03 __ Color __ Acidity __ Aluminum __ Potassi im __ Turbidity __ Alkalinity __ Antimony __ Seleniu n _ pH __ Bromide __ Arsenic __ Silver ' __ Conductivity __ Brom’ate/Chlorate/Chlorite __ Barium __ Sodiun Corrosivity (temp: “C) __ Chloride __ Beryllium __ Thallitim _ BOD (5 day) __ Cyanide __ Boron __ Vanadi jm __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Zinc _ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOs CLP __ Chemical Oxygen Demand __ Nitrogen, Ammonia" as N __ Calcium, Ca*2 __ Metals/CN __ Dissolved Oxygen __ Nitrogen, Nitrate as N __ Chromium, Total __ Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Semi-vidlatiles __ 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-Metals __ Solids, Total __ Phosphorus, Ortho as P __ Magnesium __ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates __ Manganese __ TCLP-Herbicides __ Solids. Total Volatile __ Surfactants __ Mercury __ TCLP-Volatiles __ Other:_________ _ _________ __ UV254 __ Molybdenum _ TCLP-BNAs __ Nickel

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