Chain of Custody Record, Sample AE03954, Feb 2002

NYC 9/11 Public Portal Document ACCpj 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. 1010’8 Time/Date Set: Form A-70 (rev. 10/01)

pie Type (circle one): □table . 3. Non Potable Treated Bottle #’s:.

2. Non Potable 4. Other_____________ Chain of Custody?Yes No I Time/Date Collected: Comments:_____________________________

Collected By; Agency Code: PWS #:_______ Source ID: Type Descriptor: Collected From: Bill to; c-J Location's/lndividual’s Name Name/Company

Street____________________ Street_________

City/St/Zip ■_________ City/St/Zip

Identification of Source Phone#: Fax#: Collection Point. 3 7- CA,CH, Bl? Check#: Amounts

BACTERIOLOGICAL ANALYSIS Lab#: 1

Lab#:__________________ ________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS, __ Heterotrophic Plate Count _^Tnhalomethanes (524) __ Purgeable Halocarbons (624/826(1)/ (hemodialysis & all others) "-^Volatile Halocarbons (524) __ Purgeable Aromatics (624 8260) __ Coliform P/A (Public supplies) Zu Volatile Aromatics (524) __ Coliform MPN (priv well, raw, stp) __ Acrolein & Acrylonitrile (8260) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/^^1) Z/ __ Fecal Coliform (all samples) __ Microextractables (504) __ PCB's (Arochlors) (608/8q81) __ Microscopic __ Pesticides/PCB screen (508) __ Herbicides (SMI8/6630, __ Macroscopic __ Other Pesticides (SMI 8/6^ __ PCB as Decachlorobiphenyl (508A) __ API __ Herbicides (515) __ Petroleum Hydrocarbon 10-13) __ Other:________________________ __ Pesticides (525) __ Glycols in Water ■ 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 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#: __ Color __ /Acidity __ Aluminum __ Potassium __ Turbidity __ Alkalinity __ Antimony __ Selenium _'PH __ Bromide __ Arsenic __ Silver __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium I __ 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/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 ICLP __ Solids, Suspended __ PhosphorusTotal 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

NYC-WTC_000074051