Chain of Custody Record, Sample AE03934, Feb 2002

NYC 9/11 Public Portal Document ACCn ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH I

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)

Sample Type (circle one): ^PPotable' 3. Non Potable Treated Bottle #’s: 2. Non'Potable 4: Other____________ Chain of Custody? Yes No ^13/02. Time/Date Collected: Comments: Collected By: Agency Code: PWS #:________ Source ID: .Type Descriptor: I 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 CA,CH, Bl? Check#: Amounts

. BACTERIOLOGICAL ANALYSIS Lab#: Lab#:_______________________ ORGANIC POTABLE ANALYSIS C) ‘ ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count _^::(Trihalomethanes (524) Dumoohia Halocarbons (624/8260) mo/i/Qocn\ (hemodialysis & all others) __ Purgeable u^olatile Halocarbons (524) __ Purgeable Aromatics (624/^260) __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) _yVolatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) _ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides {(608/80^1) __ Microscopic __ Microextractables (504) • _ PCB’s (Arochlors) (608/8081) __ Macroscopic :__Pesticides/PCB screen (508) __ Herbicides (SMI8/6630,8151) __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SM18/6^0) __ API __ Other:________________________ __ Herbicides (515) __ Petroleum Hydrocarbon SCa&iX34 0-13) __ Pesticides (525) . __ Glycols in Water Refrigerated?yes no __ ; Carbamate Pesticides (531) __ Acid Extractables (625/8271 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;_________________________ __ Other Pesticides (SM18/6630) pH ___________ _UCMRList 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 CaCOs __ Calcium, as CaCOa __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*2 CLP __ 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

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