Chain of Custody Record, Sample AE03954, Feb 2002

NYC 9/11 Public Portal Document ACCn ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 oi (914)231-1620 Fax (914) 231-1772 NYS-ELAP No. 1010^ Time/Date Set: Form A-70 (rev. 10/01)

SaJTiple Type (circle one): Qljpotable 3. Non Potable Treated Bottle #’s:. ~ 2. Non Potable 4. Other Chain of Custody? Yes___ No Time/Date Collected: _ 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 CA,CH, Bl? Check#: Amounts

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:_______________________ OR^NIC POTABLE ANALYSIS < ORGANIC NONPOTABLE/SOLID ANALYSIS “ __ Heterotrophic Plate Count J:^ihalomethanes (524) __ Purgeable Halocarbons (624/8:160) (hemodialysis & all others) I^Volatile Halocarbons (524) __ Purgeable Aromatics (624/826C) >. __ 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 )L^ __ Macroscopic __ Pesticides/PCB screen (508) _ Herbicides (SM18/6630,8151) __ 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 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 ___________ _UCMRList 1 RADIOCHEMICAL ANALYSIS _MtBE Only (524) Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: _ 1 Color __ Acidity __ Aluminum __ Potassium' __ Turbidity __ Alkalinity __ Antimony __ Selenium _ pH __ Bromide __ Arsenic __ Silver' __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium __ 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 CaCOa . 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-violatiies __ 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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