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-ELAP No. 10108 Time/Date Set: Form A-70 (rev. 10/01)

Sample Type (circle one): ^jlyPotable . 3. Non Potable Treated Bottle #’s: 2) G 3> » 2. Non Potable 4. Other_____________________________ Chain of Custody? Yes No Time/Date Collected: fO A [V > Comments: 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________________ City/St/Zip Identification of Source Phone#:________ Fax#: C' Collection Point -6 CA,CH, Bl? Check#: Amounts

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:___________________________ ORGANIC POTABLE ANALYSIS f ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count A^halomethanes (524) (hemodialysis & all others) __ Purgeable Halocarbons (624/8260); •, ./. Volatile Halocarbons (524) __ Purgeable Aromatics (624/8^60) __ Coliform P/A (Public supplies) Volatile Aromatics (524) Y __ Acrolein & Acrylonitrile (8260) n-- .j __ Coliform MPN (priv well, raw, stp) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (BO8/8OS) c __ Fecal Coliform (all samples) __ Microextractables (504) __ PCB’s (Arochlors) (608/8081) ), __ Microscopic . Pesticides/PCB screen (508) __ Herbicides (SM18/6630,815n __ Macroscopic __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SM18/6kro’)f~- __ API .__ Herbicides (515) __ Petroleum Hydrocarbon ScanJ(^Jtl-13) __ Other:________________________ __ 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:_______________________ J________ __ Other Pesticides (SM18/6630) pH _____________ __ UCMR List 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 CaCOs __ Calcium, as CaCOa CLP ~ __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*2 __ Metais/CN __ 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 I __ 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-ENA'S __ Nickel

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