Chain of Custody Record, Sample AE03954, Feb 2002

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

imple Type (circle one); iJPotable 3. Non Potable Treated Bottle #'s:

2. Non Potable 4. Other_____________ Chain of Custody? Yes___ No Time/Date Collected Comments: r'

Collected By: 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 C"

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

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:_____________ _____________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count _^Tnhalomethanes (524) __ Purgeable Halocarbons (624/8260)-- CC- (hemodialysis & all others) _L^olatile Halocarbons (524) __ Purgeable Aromatics (624/3260) -6 __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) _4xVolatile Aromatics (524) __ Acrolein & Acrylonitrile (82^0) __ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081) __ Microextractables (504) __ PCB’s (Arochlors) (608/86&i;^ __ Microscopic . Macroscopic __ Pesticides/PCB screen (508) _ Herbicides (SMI8/6630,815 _ API __ PCB as Decachlorobiphenyl (508A) __ ■ Other Pesticides (SMI8/663©)— __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-1^ __ Other:____________ j__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 _____________ _UCMRList1 RADIOCHEMICAL ANALYSIS _MtBEOnly (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*^ Dissolved Oxygen ‘ _ Metais/CN __ 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 I Solids, Percent (%) __ Oil and Grease __ Copper I ! __ 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 I __ TCLP-Herbicides __ Solids, Total Volatile __ Surfactants __ Mercury __ TCLP-Volatiles __ Other:____________________ _ UV254 __ Molybdenum _ TCLP-BNA's _ Nickel r- I NYC-WTC_000074053