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 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)

Jampie Type (circle one): ijpotable 3. Non Potable Treated Bottle #’s: S'o if 2. Non Potable 4. Other_____________________________ Chain of Custody? Yes___ No ' Time/Date Collected: Z’d— Comments: Collected By: Agency Code: PWS #:_________ Source ID: Type Descriptor: Collected From; Bill to; Locatiori's/lndividual’s Name_____________________________ Name/Company Street__________________________________________________ Street__________ City/St/Zip______________________________________________ City/St/Zip Identification of Source__________________________________ Phone#:________ Fax#: Collection Point _ LfO __________________ CA,CH, Bl? Check#; Amounts

BACTERIOLOGICAL ANALYSIS Lab#; Lab#:___________________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count _2:^ihalomethanes (524) __ Purgeable Halocarbons (624/8260) (hemodialysis & all others) ^jalatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) _5volatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) __ Coliform MPN (priv well, raw, sip) __ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081) __ Microextractables (504) __ PCB’s (Arochlors) (608/8081) __ Microscopic __ Macroscopic __ Pesticides/PCB screen (508) _ Herbicides (SMI8/6630,8151) r-

_ API __ PCB as Decachlorobiphenyl (508A) __ : Other Pesticides (SM18/6630) __ Other;________________________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13).,o __ Pesticides (525) __ Glycols in Water Refrigerated?yes no __ ^Carbamate Pesticides (531) _ Acid Extractables (625/8270) j> 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) r..> ) 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 _ __ A:idity __ Aluminum __ Potass urn O'. __ Turbidity __ Alkalinity __ Antimony __ SeleniJm _ pH __ Bromide __ Arsenic __ Silver I __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodiurfi __ Corrosivity (terfip;. °C) __ Chloride __ Beryllium __ 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 __ 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_000073932