Chain of Custody Record, Sample AE03954, Feb 2002

NYC 9/11 Public Portal Document ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM

idafe 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): j/. Potable 3. Non Potable Treated Bottle #'s:. 2. Non Potable 4. Other____________ Chain of Custody? Yes No Time/Date Collected; Comments; Collected By:___________ Agency Code: PWS #;________ Source ID: Type Descriptor: ’c" Collected From: Bill to: Location’s/lndividual’s Name Name/Company Street_________________ Street_________ Ci'ty/St/Zip______________ City/St/Zip 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 _A<fnhalomethanes (524) (hemodialysis & all others) __ Purgeable Halocarbons (624/8260) o _\/'Volatile Halocarbons (524) __ Purgeable Aromatics (624/82'60) ’ __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) _yVolatile Aromatics (524) __ Acrolein & Acrylonitrile (8260 __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (6(58/808 c: __ Fecal Coliform (all samples) __ Microscopic __ Microextractables (504) __ PCB's (Arochlors) (608/8081)' __ Macroscopic __ Pesticides/PCB screen (508) _ Herbicides (SMI8/6630,8151) __ API __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SM18/6630~r^— __ Herbicides (515) __ Petroleum Hydrocarbon Scan (TlO-^) __ 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:_________________________ __ 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 __ Zin'c _ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOa CLP __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*^ _ Metals/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 __ Cobalt __ Pesticides/PCB's __ Solids, Percent (%) __ Oil and Grease __ Copper __ Solids, Settleable __ Phenol __ Iron TCLP __ Solids, Suspended __ Phosphorus Total as P __ Lead r _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 1 _ Nickel

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