Chain of Custody Record, Sample AE03944, Feb 2002

NYC 9/11 Public Portal Document XK ACCn ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM Westchester WESTCHESTER COUNTY LABORATORIES AND RESEARCH 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): ^L^otable 3. Non Potable Treated Bottle #’s:

2. Non Potable 4. Other_____________ Chain of Custody?___ Yes No Time/Date Collected: jLhi Comments: Collected By; Agency Code; PWS #:_______ Source ID; Type Descriptor: Collected From: Bill to: t

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 __ Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) (hemodialysis & all others) __ Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) •__ Coliform MPN (priv well, raw, sip) __ Volatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081) __ Fecal Coliform (all samples) __ Microextractables (504) __ PCB’s (Arochlors) (608/8081) __ Microscopic __ Macroscopic __ Pesticides/PCB screen (508) __ Herbicides (SM18/6630,8151) __ API __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SMI 8/6630) _ Herbicides (515) __ Petroleum'Hydrocarbon Scan (310-13) __ Other;_______________ _ _______ __ Pesticides (525) __ Glycols in Water 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 _MtBE Only (524) ___ Radon __ Other__________ _____________

INORGANIC ANALYSIS REQUESTED - Lab#; __ Color __ /toidity __ Aluminum __ Potassiun cr - __ 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 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 __ 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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