Chain of Custody Record, Sample AE03954, Feb 2002

NYC 9/11 Public Portal Document iS A'^Cn ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 .T/ (914) 231-1620 Fax (914) 231-1772 SL NYS-ELAP No. 10108 Time/Date Set: Form AYO (rev. 10/01)

mple Type (circle one): IJPotable . 3. Non Potable Treated Bottle #’s:, □ -3 : #■ 2. Non Potable 4. Other. Chain of Custody? Yes___ Mo Time/Date Collected: Comments: Collected By:_____________ Agency Code: PWS #:_________ Source ID: Type Descriptor: 1 Collected From: Bill to: Location's/lndividual's Name Name/Company Street____________________ Street__________ I > City/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 Trihalomethanes (524) __ Purgeable Halocarbons (624/8260)' (hemodialysis & all others) _ Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) □/volatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) 5"' __ Coliform MPN (priv well, raw, stp) __ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081)' __ Microextractables (504) __ PCB's (Arochlors) (608/808l5) __ Microscopic __ Macroscopic __ Pesticides/PCB screen (508) _ Herbicides (SM18/6630,8151) __ API __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SM18/6630) __ Other:________________ ' __ Herbicides (515) __ Petroleum Hydrocarbon Scan^(310-13) __ Pesticides (525) __ Glycols in Water Refrigerated?yes no __ ^Carbamate Pesticides (531) __ Acid Extractables (625/8270)^-2^^

no __ Glyphosate (547) __ Base Neutral Extractables (625/827&)^ Chlorinated;? yes __ 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 __ Zinc _ 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-violatiies __ 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-Yolatiles __ Other:___________________ _ UV254 __ Molybdenum _ TCLP-BNA's, __ Nickel

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