Chain of Custody Record, Sample AE03934, Feb 2002

NYC 9/11 Public Portal Document ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ■ WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 diBfaci 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 No I Time/Date Collected; Comments: Collected Bv: 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 J BACTERIOLOGICAL ANALYSIS Lab#; Lab#:______ ORGANIC POTABLE ANALYSIS ' Q I ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count j^rTrihalomethanes (524) j^rTrihalomethanes (524) U __ Purgeable Halocarbons (624/8260) (hemodialysis & all others) tY^olatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) _k^olatile Aromatics (524) __ Coliform MPN (priv well, raw, stp) __ Acrolein & Acrylonitrile (8260) __ Fecal Coliform (ail samples) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081)-' __ Microscopic __ Microextractables (504) __ PCB’s (Arochlors) (608/8081) O __ Macroscopic __ Pesticides/PCB screen (508) _ Herbicides (SM18/6630,8(l51) ro _ API __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SMI8/6630) -T- __ Other:_________ :___________ __ Herbicides (515) __ Petroleum Hydrocarbon Span (310-137 _-Pesticides.(525)----------------------------------- —_::^-Glycols in-Water------------------- -------- — Refrigerated?yes no __ ; Carbamate Pesticides (531) _ Acid Extractables (625/82^?^=^ Chlorinated:? yes no __ Glyphosate (547) __ Base Neutral Extractables (625/3270) __ Diquat (549) __ GC/MS Unknown Scan i ---- • 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#;__ 4 __ 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 CaCOa __ Calcium, as CaCOa CLP __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*^ __ Dissolved Oxygen __ Metals/CN __ Nitrogen, Nitrate as N __ Chromium, Total __ Volatil es __ 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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