Chain of Custody Record, Sample AE03934, Feb 2002

NYC 9/11 Public Portal Document ACCn ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM '

S6if®«n WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 tNYS-ELAP No. 1G108 Time/Date Set; Form A-70 (rev. 10/01) 'A

Sample Type (circle one): jJPotable 3. Non Potable Treated Bottle #’s:

2. Non Potable 4. Other_____________ Chain of Custody? Yes___ No Time/Date Collected:. An 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 3 CA,CH, Bl? Check#: Amounts

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:___________________________ ORGANIC POTAi ORGANIC NONPOTABLE/SOLID ANALYSIS '■ Heterotrophic Plate Count _d^ihalomethanes (524) __ Purgeable Halocarbons (624/8260) . '. (hemodialysis & all others) L^latile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) _J<tolatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) “ __ Coliform MPN (priv well, raw, stp) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (^OS/SOsJj r- __ Fecal Coliform (all samples) __ Microextractables (504) _ PCB’s (Arochlors) (608/8081) ' __ Microscopic __ Macroscopic ;__ Pesticides/PCB screen (508) __ Herbicides (SMI8/6630,81513 ;__ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SM 18/663^^5:=’ __ API __ Herbicides (515) __ Petroleum Hydrocarbon Scan jgj5?13) __ Other:________________ _______ __ Pesticides (525) __ Glycols in Water j - Refrigerated?yes no __ ; Carbamate Pesticides (531) __ Acid Extractables (625/8270) __ Glyphosate (547) __ Base Neutral Extractables (^25/8270) Chlorinated;? yes___ no __ 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 _ MtBE Only (524) ___ Radon __ Other_______________________

INORGANIC ANALYSIS REQUESTED - Lab#; __ Color __ Acidity __ Aluminum __ Potassium __ Turbidity __ Alkalinity __ Antimony __ Selenium __ pH __ Bromide ' __ Arsenic __ Silver __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium __ Corrosivity (temp:. °C) __ Chloride __ Beryllium __ Thallium _ BOD (5 day) __ Cyanide __ Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Zinc _ Soluble BOD (5 day) __ Hardness, Total as CaCOs ___ Calcium, as CaCOs CLP __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*’ _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 _ TCLF’-Volatiles __ Other;____________________ _ UV254 __ Molybdenum _ TCLP-BNA’s __ Nickel

t NYC-WTC_000073972