Chain of Custody Record, Sample AE03944, Feb 2002

NYC 9/11 Public Portal Document ACCn ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM :§tchester M^govcorn WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914) 231-1620 Fax (914) 231-1772 NYS-ELAP No. 10i08 Time/Date Set; Form A-70 (rev. 10/01)

Sample Type (circle one): L^-15> Tc| ^Potable 3. Non Potable Treated Bottle #’s: I

2. Non Potable ■ 4. Other Chain of Custody?___ Yes No Time/Date Collected: Il IIIo.? Comments; Collected By: Agency Code: PWS #;______ Source ID: Type Descriptor: Collected From: Bill to: Location's/lndividual's Name Name/Company Street_________________ Street_______ City/SVZip______________ City/St/Zip Identification of Source Phone#; Fax#; Collection Point 3 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) Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) KxVolatile 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) __ API __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SM18/6630) SJ __ Other:__________ __________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13)";;, __ Pesticides (525) __ Glycols in Water Refrigerated?yes no __ .Carbamate Pesticides (531) „ Acid Extractables (625/8270) X-’ 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: ____________________ xl __ Other Pesticides (SM18/6630) pH ___________ __ UCMR List 1 RADIOCHEMICAL ANALYSIS _MtBE Only (524) __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: I i • C-y ' __ Color __ Acidity __ Aluminum __ Potassiuny. __ Turbidity __ Alkalinity __ Antimony __ Selenium _ pH __ Bromide __ Arsenic _ Silver ' __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium ___Sodiurn Corrosivity (temp; .°C) __ Chloride __ Beryllium _ Thallium _ BOD (5 day) _ Cyanide __ Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium _ Zinc i _ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOs CLP __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca-^z __ Dissolved Oxygen __ Nitrogen, Nitrate as N __ Metals/CN __ Chromium, Total _ Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Semi-violatiles 1_ Total Organic Halides __ Nitrogen, Total Kjeldahl as N __ Cobalt __ Pesticides/PCB's __ Solids, Percent (%) __ Oil and Grease __ Copper __ Solids, Settleable __ Phenol __ Iron ICLP __ 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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