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-ELAP No. 11)108 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; !____________ Comments; Collected By: Agency Code: PWS #:________ Source ID: Type Descriptor; Collected From: Bill to: I c? Location's/lndividual’s Name Name/Company Street_________________ Street_________ City/St/Zip______________ City/St/Zip -Identification of Source Phone#::_______ Fax#: Collection Point 32- CA,CH, Bl? Check#; Amounts

BACTERIOLOGICAL ANALYSIS Lab#: Lab#;_______________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count £r^rihalomethanes (524) (hemodialysis & all others) __ Purgeable Halocarbons (624/8260) 'Y^latile Halocarbons (524) __ Purgeable Aromatics (624/8260) c?. -.r __ Coliform P/A (Public supplies) Z^olatile Aromatics (524) __ Coliform MPN (priv well, raw, stp) __ Acrolein & Acrylonitrile (8260) g c. __ Fecal Coliform (all samples) __ Total Thhalomethane Potential (510) __ Organochlorine Pesticides !(608/8Q8,1) o; __ Microextractables (504) __ PCB's (Arochlors)'(608/80^1) q- __ Microscopic __ Macroscopic _ Pesticides/PCB screen (508) ’ __ Herbicides (SMI8/6630,8151) c __ API __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SM18/66:^J:;^ __ Other:_____________________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (31^13) __ Pesticides (525) __ Glycols in Water J Refrigerated?yes___ no __ ^Carbamate Pesticides (531) __ Acid Extractables- (625/8270) ‘ 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 ___________ __ UCMR List 1 RADIOCHEMICAL ANALYSIS _MtBEOnly (524) __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ A:idity __ 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 CaCOs ~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-violatiles __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N __ Cobalt __ Pesticides/PCB's __ Solids, Percent (%) __ Oil and Grease Copper f __ Solids, Settleable __ Phenol __ Iron tclp __ Solids, Suspended __ Phosphorus Total as P __ Lead __ TCLP-Metals __ Solids, Total __ Phosphorus, Ortho as P __ Magnesium ._2. 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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