Chain of Custody Record, Sample AE03934, Feb 2002

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

SsS®"' WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914) 231-1620 Fax (914) 231-1772 NYS-ELAP No. 1D108 Time/Date Set; Form A-70 (rev.lO/OI) i

Sample Type (circle one): ^^otable 3. Non Potable Treated Bottle #'s:

2. Non Potable 4. Other______________ Chain of Custody? Yes___ No Time/Date Collected: <3^ Comments: - Collected By: Agency Code: PWS #: _____ Source ID: Type Descriptor: Collected From: Bill to:

Location’s/lndividual's Name Name/Company ■ I Street _ __________________ street______ . City/St/Zip________________ City/St/Zip I Identification of Source Phone#:_________ Fax#: Collection Point CA,CH, Bl? Check#: Amounts

BACTERIOLOGICAL ANALYSIS Lab#: Lab#;__________________________ ORGANIC POTABLE ANALYSIS fQ “^dRGANlC NONPOTABLE/SOLID ANALYSIS

__ Heterotrophic Plate Count _£::Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) (hemodialysis & all others) _!i-Vt)latile Halocarbons (524) __ Purgeable Aromatics (624/8260) ... __ Coliform P/A (Public supplies) ( __ Coliform MPN (priv well, raw, stp) _f-VDlatile Aromatics (524)' __ Acrolein & Acrylonitrile (82.60) , __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides i?608/808'l) __ Fecal Coliform (all samples) __ Microextractables (504) _ PCB’s (Arochlors) (608/8081) 2^? __ Microscopic __ Pesticides/PCB screen (508) __ Herbicides (SM18/6630,8151) __ Macroscopic _ API __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SM18/66’;^^ __ Other;________________________ __ Herbicides (515) __ Petroleum Hydrocarbon Sc^ I ___ Pesticides (525) > ______ Glycols .in .Water__________ Refrigerated?yes___ no __ :Carbamate Pesticides. (531) __ Acid Extractables (625/827 __ Glyphosate (547) __ Base Neutral Extractables (625/8270) Chlorinated:? yes no __ Diquat (549) __ GC/MS Unknown Scan Free Chlorine Res:mg/L __ Chlorination Disinfection Byproducts (551) __ Phthalates (606MS) I Total Chlorine Res;mg/L __ Haloacetic Acids (552) __ Other:_____________________________ __ Other Pesticides (SM18/6630) pH _____________ I _UCMR List 1 RADIOCHEMICALANALYSIS _ MtBE Only (524) ___ Radon j__ 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 CLP __ Chemical Oxygen Demand __ Nitrogen. Ammonia as N __ Calcium, Ca*2 _ Metal s/CN __ Dissolved Oxygen __ Nitrogen, Nitrate as N __ Chromium, Total __ Volati les __ 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_000073964