Chain of Custody Record, Sample AE03944, 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 /a (914) 231-1620 Fax (914) 231-1772 NYS-ELAP No. 10108 Time/Date Set; Form A-70 (rev.10/01)

Sample Type (circle one): 1. Potable . 3. Non Potable Treated Bottle #’s: 2. Noh 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 CA,CH, Bl? Check#: Amounts

BACTERIOLOGICAL ANALYSIS Lab#: Lab#;______________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count ^Trihalomethanes (524) (hemodialysis & all others) __ Purgeable Halocarbons (624/8260) _:r^olatile Halocarbons (524) __ Purgeable Aromatics (624/8260) . __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) _js--Volatile Aromatics (524) __ Acrolein Acrylonitrile (8260) __ Fecal Coliform (al! samples) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081) __ Microscopic __ Microextractables (504) __ PCB’s (Arochlors) (608/8031) __ Macroscopic __ Pesticides/PCB screen (508) __ Herbicides (SM18/6630,8151) __ API __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SMI 8/6630) __ Other:_____________________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) __ 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) -c ■■

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 __ /k;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 CaCOs __ Calcium, as CaCOs I CLP __ Chemical Oxygen Demand ' __ Nitrogen, Ammonia as N __ Calcium, Ca*2 __ Nitrogen, Nitrate as N __ Chromium, Total __ Metals/CN __ Dissolved Oxygen __ Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Semi-violatiles __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N __ Cobalt I __ Pesticides/PCB's __ Solids, Percent (%) _ _ Oil and Grease __ Copper __ Solids, Settleable __ Phenol __ Iron 1 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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