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 [NYS-ELAPNo. lSlO8 Time/Date Set; Form A-70 (rev. 10/01)

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

2. Non Potable 4. Other_____________ Chain of Custody? Yes___ No Time/Date Collected::__ 6 Z /r^___ Comments: Collected By; Agency Code: PWS #;_________ Source ID: Type Descriptor: Collected From: Bill to: Location’s/lndividual’s Name 0^ Name/Company 1 Street____________________ Street City/St/Zip________________ City/St/Zip Identification of Source Phone#:________ Fax#: Collection Point CA,CH, Bl? Check#; Amounts

r . ■; BACTERIOLOGICAL ANALYSIS Lab#; Lab#:__________________________ ORGANIC POTABLE ANALYSIS Q 7 ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count j4^rihalomethanes (524) V __ Purgeable Halocarbons (624/8260) (hemodialysis & all others) jz^olatile Halocarbons (524) __ Purgeable Aromatics (624/8260) . __ Coliform P/A (Public supplies) _J<^olatile Aromatics (524) __ Coliform MPN (priv well, raw, stp) __ Acrolein & Acrylonitrile (8260) __ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081) -- __ Microscopic __ Microextractables (504) __ PCB's (Arochlors) (608/8081) H __ Pesticides/PCB screen (508) __ Herbicides (SM18/6630,'8151) ^7 __ Macroscopic __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides-(SMI816630) r' __ API __ Other;________________________ __ Herbicides (515) __ Petroleum HydrocarboniScan (310-13) __ Pesticides (525) __ Glycols in Water F Refrigerated?yes ___ no __ Carbamate Pesticides (531) __ Acid Extractables __ Glyphosate (547) __ Base Neutral ExtractablesJ6^8270) Chlorinated:? yes___ no __ Diquat (549) __ GC/MS Unknown Scani Free Chlorine Res:mg/L __ Chlorination Disinfection Byproducts (551) __ Phthalates (606MS) ' Total Chlorine Res:mg/L __ Haloacetic Acids (552) __ Other:________________ ;____________ __ :Other Pesticides (SMI8/6630) pH _____________ _UCMR’List 1 RADIOCHEMICAL ANALYSIS _ MtBE Only (524) ___ Radon __ Other_______________________

INORGANIC ANALYSIS REQUESTED - Lab#; __ Color __ Acidity __ Aluminum __ Potassium __ Turbidity __ Alkalinity __ Antimony __ Selenium — pH __ Bromide __ Arsenic __ Silver j__ 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 CaCOs __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*2 Se _ Metal s/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, To.tal Dissolved __ Sulfates __ Manganese __ TCLP-Herbicides __ Solids, Total Volatile __ Surfactants __ Mercury _ TCLF’-Volatiles __ Other; ___________ _________ UV254 __ Molybdenum __ TCLP-BNA's __ Nickel.

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