Chain of Custody Record, Sample AE03944, Feb 2002

NYC 9/11 Public Portal Document ACCq 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-ELAPNo. 10-108 Time/Date Set: Form A-70 (rev.10/01)

Sample Type (circle one): I ^^^otable 3. Non Potable Treated Bottle #'s: 2.'Non Potable 4. Other____________ Chain of Custody?___ Yes No Time/Date Collected; n £3— _______ Ah. I ox. 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 "S-S'3 VO 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) _i^<Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) ■ Volatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) ;: __ Fecal Coliform (all samples) _ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081) __ Microscopic __ Microextractables (504) _ PCB’s (Arochlors) (608/8081) __ Macroscopic __ Pesticides/PCB screen (508) __ Herbicides (SM18/6630,8151) b‘; __ 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 r. Free Chlorine Res;mg/L __ Chlorination Disinfection Byproducts (551) _ Phthalates (606MS) Total Chlorine Res:mg/L __ Haloacetic Acids (552) __ Other:___________________________ __ Other Pesticides (SMI8/6630) pH ___________ __ UCMR List 1 RADIOCHEMICAL ANALYSIS _MtBE Only (524) __ Radon __ Other____________________ j

INORGANIC ANALYSIS REQUESTED - Lab#; __ Color __ Acidity __ Aluminum __ Potassium __ Turbidity __ Alkalinity __ Antimony ' Seleniurfi _ pH __ Bromide __ Arsenic _ ■_ Silver __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium, Corrosivity (temp: °C) __ Chloride __ Beryllium _ Thallium _ BOD (5 day) __ Cyanide __ Boron _2 Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Zinc _ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOs __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca+2 Sp __ Nitrogen, Nitrate as N _ Metals/CN __ Dissolved Oxygen __ 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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