Chain of Custody Record, Sample AE03944, Feb 2002

NYC 9/11 Public Portal Document ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH 4 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): 1 ^^otable . 3. Non Potable Treated Bottle #'s: 2. Non Potable 4. Other Chain of Custody? Yes No Time/Date Collected: Il -^4?^ _____________ Comments: Collected By: Agency Code: PWS #:________ Source ID; Type Descriptor: Collected From: Bill to: 1 Location’s/lndividual's Name Name/Company Street_________________ Street_________ 1

City/St/Zip______________ City/St/Zip Identification of Source .Phone#:_______ Fax#: Collection Point -4 CA,CH. Bl? Check#: Amounts

BACTERIOLOGICAL ANALYSIS Lab#: 1 Lab#:_______ ________________ ORGANIC PO ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count J^fTrihalomethanes (524) __ Purgeable Halocarbons (624/8260) (hemodialysis & all others) _vA7blatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) ■XYolatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) __ Fecal Coliform (all samples) __ Total Trihaiomethane Potential (510) __ Organochlorine Pesticides (608/8081) (i.) __ Microscopic __ Microextractables (504) _ PCB's (Arochlors) (608/8081) __ Macroscopic __ Pesticides/PCB screen (508) __ Herbicides (SMI8/6630,8151) E _ API _ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SMI8/6630) __ 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 ___________ _UCMRList1 RADIOCHEMICAL ANALYSIS _MtBE Only (524) __ Radon __ Other_______________ _____

INORGANIC ANALYSIS REQUESTED - Lab#: tX' __ Color __ /Acidity __ Aluminum __ Potassium __ , Turbidity __ Alkalinity __ Antimony __ Selenium , _ pH __ Bromide __ Arsenic __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium , / __ Corrosivity (temp: ’C) __ Chloride __ Beryllium __ Thallium I _ BOD (5 day) __ Cyanide __ Boron __ Vanadium: __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Zinc — t _ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOs 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, Settleabie __ 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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