Chain of Custody Record, Sample AE03917, Feb 2002

NYC 9/11 Public Portal Document ACCo 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. 1O'lO8 Time/Date Set: Form A-70 (rev. 10/01)

Sample Type (circle one): ■ /iJPotable 3. Non Potable Treated Bottle #'s: 2. Non Potable ■ 4. Other_________________ _____ Chain of Custody? Yes No C’.

Time/Date Collected: // v > Comments: Collected By: Agency Code: PWS #:________ Source ID: Type Descriptor: Collected From: Bill to: J Location’s/lndividual’s Name______________ ____________ Name/Company Street________________;____________ ________________ Street_________ -f- City/St/Zip_________________________________________ City/St/Zip Identification of Source_______________________________ Phone#:_______ Fax#:', Collection Point I CA,CH, Bl? Check#; Amounts

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:_______________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count _3rrihalomethanes (524) ■' __ Purgeable Halocarbons (624/8^60) —I (hemodialysis & all others) ^"'^latile Halocarbons (524) __ Coliform P/A (Public supplies) __ Purgeable Aromatics (624/8260^ __ Coliform MPN ' (priv well, raw, stp) _3Volatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) , __ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081) __ Microscopic __ Microextractables (504) __ PCB’s (Arochlors) (608/8081) i '7' __ Pesticides/PCB screen (508) _ Herbicides (SMI8/6630,8151) 1 3 __ Macroscopic _ API __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SMI 8/6630) '■ __ Other:_____________________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) _o __ 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) 3 Total Chlorine Res;mg/L __ Haloacetic Acids (552) __ Other:_______________ __ Other Pesticides (SM18/6630) pH ___________ _UCMRList 1 RADIOCHEMICAL ANALYSIS _ MtBE Only (524) __ Radon !__ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Acidity __ Aluminum __ Potassium __ Turbidity __ Alkalinity __ Antimony __ Selenium c..': _ pH __ Bromide __ Arsenic __ Silver’ __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium j __ Corrosivity (temp:. °C) __ Chloride __ Beryllium __ Thallium ! _ BOD (5 day) __ Cyanide __ Boron __ Vanadiunj __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Zinc _ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOa CLP __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*2 __ 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-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

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