Chain of custody record, Westchester County Lab, Feb 2002

NYC 9/11 Public Portal Document ACCn ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM A^festchester if- WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York ,10595 (914) 231-1620 Fax (914) 231-1772 •Y xlJ

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

^mple Type (circle one): (jZ Potable . 3. Non Potable Treated Bottle #’s: 4&T3- 2. Non Potable 4. Other • Chain of Custody? Yes___ No Time/Date Collected: (b- A. f 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#: Collection Point, -------------- I CA,CH, Bl? Check#: Amounts

t BACTERIOLOGICAL ANALYSIS Lab#: Lab#:__________________________ _ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count _irTrthalomethanes (524) __ Purgeable Halocarbons (624/8260) (hemodialysis & all others) _2:fVolatile Halocarbons (524) __ Purgeable Aromatics (624/8260) ,., __ Coliform P/A (Public supplies) _J<t7oiatile Aromatics (524) __ Coliform MPN (priv well, raw, stp) __ Acrolein & Acrylonitrile (8260) __ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081-P __ Microscopic __ Microextractables (504) _ PCB’s (Arochlors) (608/8081) CC __ Pesticides/PCB screen (508) __ Herbicides (SM18/6630,8151) __ Macroscopic _ API __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SMI 8/6630) __ Other: __ _____________________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan : (310-13) __ Pesticides (525) __ Glycols in Water "Vr> Refrigerated?yes no __ Carbamate Pesticides (531) __ Acid Extractables (625/8270) Chlorinated:? yes no __ Glyphosate (547) __ Base Neutral Extractables (62g?§27Tdx __ 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 _____ _______ _UCMRList 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, Cat^ _ Metals/CM __ Dissolved Oxygen __ Nitrogen, Nitrate as N __ Chromium, Total __ Chrom'ium, Hexavalent __ Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ 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 ,_i_TCLP-Netals __ Solids, Total __ Phosphorus, Ortho as P __ Magnesium __ T CLP-Pesticides __ Solids, Total Dissolved __ Sulfates __ Manganese __ TCLP-Herbicides __ Solids, Total Volatile __ Surfactants __ Mercury __ TCLP-Volatiles __ Other:___________________ _ UV254 __ Molybdenum __ TCLP-BNA's __ Nickel

NYC-WTC_000074092