Chain of Custody Record, Sample AE03934, Feb 2002

NYC 9/11 Public Portal Document ACCo 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. liJlO8 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: fI oZ Comments; Collected By: Agency Code; PWS #:________ Source ID: Type Descriptor: Collected From: Bill to; Location's/lndividual’s Name. QWj?_______ Name/Company Street_____________ Street_________ City/St/Zip_________ City/St/Zip Identification of Source Phone#:_______ Fax#; Collection Point 33 CA,CH, Bl? Check#: Amounts

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:________________________ ORGANIC POTABLE ANALYSIS*^ 1 ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count _L^rihalomethanes (524) __ Purgeable Halocarbons (624/8260) (hemodialysis & all others) L^olatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) _ywlatile Aromatics (524) __ Acrolein & Acrylonitrile (8260),-, __ . Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081) __ Microextractables (504) __ PCB's (Arochlors) (608/^081) 'Z', __ Microscopic __ Herbicides (SM18/6630,^151) ij? __ Pesticides/PCB screen (508) __ Macroscopic __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SM18/6630) _ API __ Other:_____________________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-T3)' __ Pesticides (525) __ Glycols in Water ' J Refrigerated?yes___ no __ , Carbamate Pesticides (531) __ Acid Extractables (625/8amj-^ __ Glyphosate (547) __ Base Neutral Extractabler(62^270) Chlorinated;? yes no _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 ___________ _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 __ 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 _ Metals/CN __ Dissolved Oxygen __ Nitrogen, Nitrate as N __ Chromium, Total __ Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Semi-violatiies __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N __ Cobalt Pesticides/PCB's __ Solids, Percent (%) __ Oil and Grease __ Copper __ Solids, Settleable __ Phenol __ Iron Iclp: '__ 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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