Chain of Custody Record, Sample AE03954, Feb 2002

NYC 9/11 Public Portal Document ACCn ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM .JJSfestehester WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914) 231-1620 Fax (914) 231-1772 NYS-ELAP No. 10108 Time/Date Set; Form A-70 (rev.10/01)

mple Type (circle one): Bottle #'s:. US~5~^ Zflb #■ iJPotable 3. Non Potable Treated 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 _G Street_________________ Street_________ City/St/Zip______________ City/St/Zip Identification of Source Phone#:_______ Fax#: Collection Point CA,CH, Bl? Check#: Amounts C-,

BACTERIOLOGICAL ANALYSIS Lab#: Lab#;_______________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count _^Trrhalomethanes (524) (hemodialysis & all others) __ Purgeable Halocarbons (624/8260) .. Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) o o * __ Coliform P/A (Public supplies) __ Acrolein & Acrylonitrile (82^0) C __ Coliform MPN (priv well, raw, stp) Volatile Aromatics (524) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (fe08/8061) CO __ Fecal Coliform (all samples) __ Microscopic __ Microextractables (504) __ PCB's (Arochlors) (608/80811) -< ..f __ Pesticides/PCB screen (508) __ Herbicides (SMI 8/6630,81 5^ES-5. C' __ Macroscopic __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SMI8/6630^ __ API __ Other:____________ ________ __ Herbicides (515) __ Petroleum Hydrocarbon Scdrr“(340-13) __ Pesticides (525) Glycols in Water • V 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: t _Other Pesticides (SMI8/6630) pH ___________ _UCMRList 1 RADIOCHEMICAL ANALYSIS _MtBEOnly (524) __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: _ __ Color __ /V:idity __ 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 Carbori __ 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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