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 I 2 Dana Road, Valhalla, New York 10595 I (914) 231-1620 Fax (914) 231-1772 NYS-ELAPNo. 10108 Time/Date Set: Form A-70 (rev. 10/01)

Sample Type (circle one); TA 0 Potable . 3. Non Potable Treated Bottle #'s;

2. Non Potable 4. Other __j_________________________ Chain of Custody? Yes__ _ Mo Time/Date Collected: I Itri_____ ________ ^)ii I ciL- Comments: Collected By: Agency Code: PWS #:_________ Source ID: Type Descriptor; Collected From; ‘ Bill to: Location’s/lndividual's Name Name/Company street____________________ Street_______ _ I City/St/Zip________________ City/St/Zip Identification ‘of Source Phone#: Fax#: Collection Point I CA,CH, Bl? Check#: Amounts ,1

BACTERIOLOGICAL ANALYSIS Lab#: Lab#;___________________________ ORGANIC POTABLE ANALYSIS/ ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count _:^Trihalomethanes (524) (hemodialysis & all others) __ Purgeable Halocarbons (624/8260) j<Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) ■ '^^olatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) __ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081) ' __ Microextractables (504) __ PCB’s (Arochlors) (608/8081) __ Microscopic __ Macroscopic __ Pesticides/PCB screen (508) __ Herbicides (SM18/6630,8151) __ API __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SM18/6630) __ 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) Total Chlorine Res; mg/L __ Haloacetic Acids (552) __ Other: ■ __ Other Pesticides (SM18/6630) pH _____________ __ -UCMRList 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 I CC’ -O __ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOs CLP I. __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca-"2 __ Dissolved Oxygen __ Metals/CN __ 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-Voiatiles _ Other;___________________ _ UV254 __ Molybdenum _ TCLP-BNA's __ Nickel

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