Chain of Custody Record, Sample AE03954, Feb 2002

NYC 9/11 Public Portal Document

St#™, ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 g(.i (914)231-1620 Fax (914) 231-1772 NYS-ELAP No. 10108 Time/Date Set: Form A-70 (rev. 10/01)

Sample Type (circle one); ^^Potable 3. Non Potable Treated Bottle #’s:, it 2. Non Potable 4. Other____________________________ Chain of Custody? Yes___ No Time/Date Collected:. ^f^fp Comments; Collected By:______________ Agency Code: PWS #;_________ Source ID: Type Descriptor: Collected From; Bill to; Location’s/lndividual’s Name, Name/Company t

Street____________________ Street__________ City/St/Zip________________ City/St/Zip Identification of Source Phone#:________ Fax#: Collection Point —3 CA.CH, Bl? Check#: Amounts

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:__________________________ ORGANIC POTABLE ANALYSIS f ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count J::^rihatomethanes (524) (hemodialysis & all others) __ Purgeable Halocarbons (624/8260) 'olatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) _yv(tolatile'Aromatics (524) __ Acrolein & Acrylonitrile (8260) c:. __ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides !(6O8/80&1) __ Microscopic __ Microextractables (504) __ PCB’s (Arochlors) (608/80pi) r- __ Macroscopic __ Pesticides/PCB screen (508) _ Herbicides (SM18/6630,8151) __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SM’i 8/6(530) _ API c __ Other:________________________ __ Herbicides (515) __ Petroleum Hydrocarbon ^^n (310-13) __ Pesticides (525) __ Glycols in Water ’ Refrigerated?yes___ no __ Carbamate Pesticides (531) __ Acid Extractabies (625/827I __ Glyphosate (547) __ Base Neutral Extractabies'^ 70) 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 (SMI8/6630) pH _____________ __ UCMR List 1 RADIOCHEMICAL ANALYSIS _MtBE Only (524) ___ Radon __ Other_______________________

INORGANIC ANALYSIS REQUESTED - Lab#; __ Color __ A: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 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 I __ 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-Volatiles __ Other:___________________ _ UV254 __ Molybdenum _ TCLP-BNA's __ Nickel

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