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 NYS-ELAP No. 1'0108 Time/Date Set; Form A-70 (rev. 10/01)

iample Type (circle one): r iJPotable 3. Non Potable Treated Bottle #'s:

2. Non Potable 4. Other___________________________ Chain of Custody?___ Yes No Time/Date Collected: il'- Lf f Comments: ---------------------- -V Collected By:_____________ Agency Code; PWS #:_______ Source ID: Type Descriptor: Collected From: Bill to; Location’s/lndividual's Name Name/Company Street____________________ Street_________ City/SVZip________________ City/St/Zip Identification of Source Phone#; Fax#: Collection Point /b 3-^ CA,CH, Bl? Check#: Amounts

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:____________________ ___ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count _YXrihalomethanes (524) __ Purgeable Halocarbons (624/8260) (hemodialysis & all others) __:^^latile Halocarbons (524) __ Coliform P/A (Public supplies) __ Purgeable Aromatics (624/8260) ■Volatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) i __ Coliform MPN (priv well, raw, stp) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608’/8081) __ Fecal Coliform (all samples) __ Microextractables (504) _ PCB’s (Arochlors) (608/8081) \ __ Microscopic __ Pesticides/PCB screen (508) __ Herbicides (SM18/6636,8151) __ Macroscopic _ API __ RGB 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) 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#: CC 'S- __ Color __ Acidity __ Aluminum __ Potassium __ Turbidity __ Alkalinity __ Antimony __ Selenium _ pH __ Bromide __ Arsenic __ Silver __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium __ Corrosivity (temp:_ °C) __ Chloride __ Beryllium __ Thallium _ BOD (5 day) __ Cyanide __ Boron __ Vanadium __ 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*^ _ Metals/CN __ Dissolved Oxygen __ Nitrogen, Nitrate as N __ 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 ICLP __ 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-BNA’s __ Nickel

NYC-WTC_000073926