Chain of Custody Record, Sample AE03954, Feb 2002

NYC 9/11 Public Portal Document ACCn ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ,^fetohester WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 S/ (914) 231-1620 Fax (914) 231-1772 NYS-ELAP No. 10108 Time/Date Set: Form AYO (rev. 10/01)

imple Type (circle one): 1. Potable 3. Non Potable Treated Bottle #'s: 2. Non Potable 4. Other____________ Chain of Custody? Yes No !■

Time/Date Collected: Comments; Collected By:1 Agency Code: PWS #:________ Source ID: Type Descriptor: Collected From; Bill to: Location's/lndividual’s Name Name/Company Street_________________ Street_________ City/St/Zip______________ Citv/St/Zio I

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

BACTERIOLOGICAL ANALYSIS Lab#:_______________________ __ Heterotrophic Plate Count Lab#: ew# ORGANIC POTABLE ANALYSIS _A^rihalomethanes (524) ( ORGANICNONPOTABLE/SOLID^NALYSiS __ Purgeable Halocarbons (624/8260) CC' (hemodialysis & all others) V Volatile Halocarbons (524) __ Purgeable Aromatics (624/8261) “*■■■ __ 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 (6Q§^81) __ Microscopic __ Microextractables (504) __ PCB’s (Arochlors) (608/8081)4^1==’ __ 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 (SMI8/6630) pH -------------------- _UCMRList 1 RADIOCHEMICAL ANALYSIS _MtBE Only (524) __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: __ 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*^ _ 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-Volatiies __ Other;__________________ _ UV254 __ Molybdenum __ TCLP-BNA's _ Nickel

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