Chain of Custody Record, Sample AE03934, Feb 2002

NYC 9/11 Public Portal Document X-:! 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 I X

NYS-ELAP No. 10108 Time/Date Set: Form A-70 (rev.10/01)

Sample Type (circle one): ^Potable 3. Non Potable Treated Bottle #'s: 2. Non Potable 4. Other____________ Chain of Custody?___ Yes Mo Time/Date Collected: Comments; Collected By: Agency Code: PWS #;______ Source ID; Type Descriptor: -O Collected From: Bill to; J-'’ Location’s/lndividual’s Name . Name/Company Street_________________ Street________ City/St/Zip r- City/St/Zip______________ Identification of Source Phone#: ' Fax#: Collection Point CA.CH, Bl? Check#: Amounts.

J BACTERIOLOGICAL ANALYSIS Lab#: L2 Lab#:_______________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLiD A'ffALYSIS __ Heterotrophic Plate Count _^rfTrhalomethanes (524) __ Purgeable Halocarbons (524/82^) (hemodialysis & all others) CP ty^xilatile Halocarbons (524) __ Purgeable Aromatics (3:2^SeO) ' I ■ ■ __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, sip) _yvolatile Aromatics (524) __ Acrolein & Acrylonitrile __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides^^875O81) __ Fecal Coliform (all samples) __ Microscopic __ Microextractables (504) _ PCB’s (Arochlors) (608/8081) __ Pesticides/PCB screen (508) __ Herbicides (SM18/6630.8‘l51) __ Macroscopic _ API _ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SM18/6630) __ Other:_____________________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) __ Pesticides (525) __ Glycols in Water Refrigerated?yes nd __ 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:. 1 __ Other Pesticides (SMI8/6630) pH ___________ __ UCMR List 1 RADIOCHEMICAL ANALYSIS _MtBE Only (524) __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#; __ Color __ /'cidity __ 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 CaCOa __ Calcium, as CaCOa __ Calcium, Ca*2 CLP __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N _ Mefals/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 I- 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

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