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 (914) 231-1620 Fax (914) 231-1772 f(D X

NYS-ELAP No. 1(7108 Time/Date Set; Form A-70 (rev.10/01)

Sample Type (circle one): ' 1 .Votable 3. Non Potable Treated Bottle #'s: So 5-^ . ^^Non Potable • 4. Other Chain of Custody?___ Yes____ No J Time/Date Collected: f 0 - 2-^ Comments: Collected By:_________________ Agency Code: PWS #:_______ Source ID: Type Descriptor: Collected From: Bill to: c,:.' Location’s/lndividual’s Name Name/Company Street___________________ __ Street_________ =r"i City/St/Zip____________________ City/St/Zip Identification of Source Phone#: Fax#:. Collection Point. I CA.CH, Bl? Check#; Amounts

BACTERIOLOGICAL ANALYSIS Lab#: Lab#;__________________________ OR^NIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count J/Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) (hemodialysis & all others) ^olatile Halocarbons (524) __ Coliform P/A (Public supplies) __ Purgeable Aromatics (624/8260) _l/volatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) i ^3 __ Coliform MPN (priv well, raw, stp) __ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608'8081)^-^-. __ Microscopic __ Microexfractables (504) _ PCB's (Arochlors) (608/8081) __ Macroscopic __ Pesticides/PCB screen (508) _ Herbicides (SMI8/6630,8151) — __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SMI8/6630) i -- __ API _ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) __ Other:________________________ __ Pesticides (525) __ Glycols .in Water j Refrigerated? yes no __ ^Carbamate Pesticides (531) _ Acid Extractabies (626/8270) • “

Chlorinated:? yes___ no __ Glyphosate (547) __ Base Neutral Extractabies (625/8270) r-' __ 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 _____________ _UCMRList1 RADIOCHEMICAL ANALYSIS _MtBE Only (524) ___ Radon __ Other__________ „_________ _

INORGANIC ANALYSIS REQUESTED - Lab#: -< __ Color __ Acidity __ Aluminum __ Potassium __ Turbidity __ -Alkalinity __ Antimony J_ Selenium j _ pH __ Bromide __ Arsenic __ Silver __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium ■ Sodium __ Corrosivity (temp:. °C) __ Chloride __ Beryllium __ Thallium _ BOD (5 day) __ Cyanide __ Boron Vanadium j __ 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*^ CLP __ Metals/CN __ Dissolved Oxygen __ Nitrogen, Nitrate as N __ Chromium, Total I 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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