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 4 O i fl I ’Vt"

(914)231-1620 Fax (914) 231-1772 NYS-ELAP No. 10108 Time/Date Set; I Form A-70 (rev. 10/01)

Sample Type (circle one): Potable 3. Non Potable Treated Bottle #’s: I 2. Non Potable 4. Other_____________ Chain of Custody?___ Yes Mo Time/Date Collected: Comments: Collected By: 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

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:__________________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count _4-^rThalomethanes (524) __ Purgeable Halocarbons (624/8260) c (hemodialysis & all others) J^r^latile Halocarbons (524) __ Purgeable Aromatics (624/82,60) __ Coliform P/A (Public supplies) _^:fvolatile Aromatics (524) __ Acrolein & Acrylonitrile (826C) o __ Coliform MPN (priv well, raw, stp) __ Organochlorine Pesticides (6)8/8084$; __ Total Trihalomethane Potential (510) c __ Fecal, Coliform (all samples) __ Microscopic __ Microextractables (504) _ PCB's (Arochlors) (608/808T __ Macroscopic __ Pesticides/PCB screen (508) __ Herbicides (SM18/6630,8151f='r= __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SM18/6630')^_J7? _ API __ Other:_______________________ __ Herbicides (515) __ Petroleum Hydrocarbon Scani'fTTCFtS) __ Pesticides (525) __ Glycols in Water , I Refrigerated?yes___ no __ : Carbamate Pesticide's (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 I 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 CaCOs __ Calcium, as CaCOs CLP __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*2 _ Metal s/CN __ Dissolved Oxygen __ Nitrogen, Nitrate as N __ Chromium, Total __ Volati les __ 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 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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