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 , t 2 Dana Road, Valhalla, New York 10595 (914) 231-1620 Fax (914) 231-1772 NYS-ELAP No. 10108 Tirtie/Date Set; Form A-70 (rev. 10/01)

^mple Type (circle one); f 1J Potable 3. Non Potable Treated Bottle #’s; ^117 /tthit 2. Non Potable 4. Other_____________________________ Chain of Custody? Yes No Time/Date Collected:. Comments:_____ ; Collected By: Agency Code: PWS #: _____ Source ID: Type Descriptor: i Collected From: Bill to: Location's/lndividual’s Name________ i__ 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#: Lab#;___________________ :_______ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count _^ihalomethanes. (524) __ Purgeable Halocarbons (624/8260) (hemodialysis & all others) ^jolatile Halocarbons (524) , __ Purgeable Aromatics (624/8260) . __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) _^^Wolatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) __ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081) __ Microextractables (504) __ PCB's (Arochlors) (608/8081) __ Microscopic __ Pesticides/PCB screen (508) __ Herbicides (SMI8/6630,8151) _ Macroscopic __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SM18/6630) __ API __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) __ Other:________________________ __ Pesticides (525) __ Glycols in Water Refrigerated?yes no __ ^Carbamate Pesticides (531) __ Acid Extractables (625/8270) o: 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#: __ Color __ Acidity __ Aluminum __ Potassium __ Turbidity __ Alkalinity __ Antimony __ Seleniurn' _ pH __ Bromide __ Arsenic _ Silver 1 __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium I co __ Corrosivity (temp: “C) __ Chloride __ Beryllium __ Thalli urrl _ BOD (5 day) __ Cyanide __ Boron __ VanadiiJm _ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Zinc J __ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOs CLP 1 __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca-'z ! _ Metal 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 __ TCLP-Herbicides __ Solids, Total Volatile __ Surfactants __ Mercury __ TCLP-Volatiles __ Other:____________________ _ UV254 __ Molybdenum __ TCLP-BNA’s __ Nickel '

NYC-WTC_000073930