Chain of Custody Record, Sample AE03917, Feb 2002

NYC 9/11 Public Portal Document V:, AC Co 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. 10108 Time/Date Set: Form A-70 (rev.10/01)

Sample Type (circle one); ^Potable 3. Non Potable Treated Bottle #’s:. 5- 0 y # 2. Non Potable 4. Other _______________________ Chain of Custody? Yes___ No Time/Date Collected:. iO-fi) «g. on r^( tiff 03 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#;___________________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count __ Purgeabie Halocarbons (624/8260) _vzT^alomethanes (524) (hemodialysis & all others) volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) _i^olatile Aromatics (524) __ Coliform MPN (priv well, raw, stp) __ Acrolein & Acrylonitrile (8260) __ 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 (SM18/6630,8151) __ Macroscopic __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SM18/6630) _ API __ Other:_______________________ _ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) r- __ Pesticides (525) __ Glycols in Water ■Refrigerated?yes no __ ^Carbamate Pesticides (531) __ Acid Extractables (625/8270) no __ Glyphosate (547) _ Base Neutral Extractables (625/8270) Chlorinated;? yes __ 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 (SMI8/6630) pH _____________ __ UCMR List 1 RADIOCHEMICAL ANALYSIS _MtBE Only (524) ___ Radon __ Other_______________________

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ /Ysidity __ Aluminum _j_ Potass um __ Turbidity __ Alkalinity _ Antimony __ Selenidm _ pH __ Bromide __ Arsenic __ Silver __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium __ Corrosivity (temp:. °C) __ Chloride __ Beryllium _L Thallium _ BOD (5 day) __ Cyanide __ Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Zinc ! __ Soluble BOD (5 day) __ Hardness, Total as CaCOa ___ Calcium, as CaCOa “CLP i __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*2 _Met^s/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 TCLP __ Solids, Suspended __ Phosphorus Total as P __ Lead _TCLP-Metals __ Solids, Total __ Phosphorus, Ortho as P __ Magnesium _TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates __ Manganese t TCLP-Herbicides __ Solids, Total Volatile __ Surfactants __ Mercury _ TCLP-Volatiles __ Other:_________ :_________ _ UV254 __ Molybdenum _ TCLP-BNA's __ Nickel

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