Chain of Custody Record, Sample AE03954, Feb 2002

NYC 9/11 Public Portal Document iTt ACC a 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. 101OT Time/Date Set; Form A-70 (rev. 10/01)

Sample Type (circle one): Polable 3. Non Potable Treated Bottle #'s: 2. Non Potable 4. Other Chain of Custody? Yes No Time/Date Collected: Comments: C7

Collected By:. Agency Code; PWS #:________ Source ID: Type Descriptor:q 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________ f CA.CH, Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS Lab#: Lab#; _______________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOUD ANALYSIS __ Heterotrophic Plate Count _^rTYihalomethanes (524) (hemodialysis & all others) __ Purgeable Halocarbons (621/82605^ V^olatile Halocarbons (524) __ Purgeable Aromatics (624/t 260) __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) Volatile Aromatics (524) __ Acrolein & Acrylonitrile (82^ __ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (6( '8081) __ Microextractables (504) __ PCB’s (Arochlors) (608/80^ __ Microscopic __ Macroscopic __ Pesticides/PCB screen (508) __ Herbicides (SMI8/6630,8151) _ API __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SMI 8/6630) _ __ 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:____________________ .______ pH ___________ __ Other Pesticides (SM18/6630) 1 _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 CaCOa __ Calcium, as CaCOs CLP __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*2 _ Metals/CM __ 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 I __ 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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