Chain of Custody Record, Sample AE03944, Feb 2002

NYC 9/11 Public Portal Document ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ’ ..J&gtohester WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 sdU elci NYS-ELAPNo. 10108 Time/Date Set: Form A-70 (rev. 10/01)

Sample Type (circle one); ^Potable 3. Non Potable Treated Bottle #’s: <0 Mj 2. Non Potable 4. Other________________________________ Chain of Custody? ___Yes No Time/Date Collected: _ lb A/n___________ Comments: Collected By: Agency Code: . PWS #:_______ Source ID: Type Descriptor: Collected From: Bill to: I

Location's/lndividual’s Name Name/Company Street____________________ Street_________ City/St/Zip________________ City/St/Zip

Identification of Source Phone#: Fax#: Collection Point CA,CH, Bl? Check#: Amounts

BACTERIOLOGICAL ANALYSIS Lab#: Lab#;___________________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count j^^Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) (hemodialysis & all others) Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) . __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) 21 Volatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081))’ __ Fecal Coliform (all samples) __ Microextractables (504) _ PCB's (Arochlors) (608/8081) r __ Microscopic Ci __ Pesticides/PCB screen (508) __ Herbicides (SM18/6630,8151) __ Macroscopic __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SMI 8/6630) _ API __ Herbicides (515)' __ Petroleum Hydrocarbon Scan (310-13)- __ Other:________________________ __ Pesticides (525) 4, __ Glycols in Water . j’-, Refrigerated?yes no __ ^Carbamate Pesticides (531) __ Acid Extractables (625/8270) -- __ Glyphosate (547) __ Base Neutral Extractables (625/8270)' Chlorinated:? yes___ no __ Diquat (549) __ GC/MS Unknown Scan 'Y 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 _____________ __ UCMR List 1 RADIOCHEMICAL ANALYSIS _MtBE Only (524) ___ Radon __ Other_______________________

INORGANIC ANALYSIS REQUESTED - Lab#: ■ -

I __ Potassium ' ' __ Color __ Acidity __ Aluminum __ Turbidity __ Alkalinity - Antimony _ pH __ Bromide __ Arsenic __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium __ Corrosivity (temp:. .°C) __ Chloride __ Beryllium _ Thalliuhn _ BOD (5 day) _ Cyanide __ Boron Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Zinc ’ _ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOa "CLP __ 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 I __ 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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