Chain of Custody Record, Sample AE03917, Feb 2002

NYC 9/11 Public Portal Document ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ■Afej^hester WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 O Zl 1

(914) 231-1620 Fax (914) 231-1772 ;Jj NYS-ELAP No. 10108 Time/Date Set: Form A-70 (rev. 10/01)

pie Type (circle one): otable . 3. Non Potable Treated Bottle #’s: ‘ /Ab if 2. Non Potable ■ 4. Other______________________________ Chain of Custody?___ Yes____ No Time/Date Collected:. 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 —----------- I CA,CH, Bl? Check#: Amounts

BACTERIOLOGICAL ANALYSIS Lab#; Lab#:___________________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count j/Trihalomethanes (524) (hemodialysis & all others) __ Purgeable Halocarbons (624/8260) L^olatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, sip) _5/Volatile 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) __ Macroscopic __ Pesticides/PCB screen (508) _ Herbicides (SM18/6630,8151) __ API __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SMI 8/6630) __ Other:________________________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13)7-, __ 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 _____________ _UCMRList 1 RADIOCHEMICAL ANALYSIS _MtBEOnly (524) ___ Radon __ Other_______________________

INORGANIC ANALYSIS REQUESTED - Lab#: ! __ Color __ Acidity __ Aluminum __ Potassium ce; __ Turbidity __ Alkalinity __ Antimony __ Selenium _ pH __ Bromide __ Arsenic ' Silver __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium J __ SodiumI __ Corrosivity (temp;. “C) __ Chloride __ Beryllium __ Thalliurn _ BOD (5 day) __ Cyanide __ Boron __ Vanadidm __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Zinc ; __ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOa CLP __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*2 _ 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 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_000073931