Chain of Custody Record, Sample AE03944, Feb 2002

NYC 9/11 Public Portal Document A.i;co 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-ELAP No. 10.108 Time/Date Set: Form A-70 (rev. 10/01)

Sample Type (circle one): M Ic] (^Potable 3. Non Potable Treated Bottle #’s: 2. Non Potable 4. Other_____________ Chain of Custody? Yes___ No Time/Date Collected: Comments: Collected By: Aigency 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 6’15'50 CA,CH. Bl? Check#; Amounts

BACTERIOLOGICAL ANALYSIS Lab#: Lab#;_________ ______________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count -i^LTrihalomethanes (524) __ Purgeable Halocarbons (624/8260) (hemodialysis & all others) JiifVolatile Halocarbons (524) __ Purgeable Aromatics (624/8260) . __ Coliform P/A (Public supplies) _2^^olatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) __ . Coliform MPN (priv well, raw, stp) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/808l5> __ Fecal Coliform (all samples) __ Microscopic __ Microextractables (504) __ PCB's (Arochlors) (608/8081) __ Macroscopic __ Pesticides/PCB screen (508) _ Herbicides (SM18/6630,8151) __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SM18/6630) c.;. __ API __ 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) -7 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#: j c; __ Color __ Acidity __ Aluminum __ Potassjum __ Turbidity __ Alkalinity __ Antimony __ SeleniUn/7yi J _ pH __ Bromide __ Arsenic _ Silver __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium I __ Sodiurn __ 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 £LP __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*^ __ 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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