Chain of custody record, Sample AE04125, Feb 2002

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM cMcr WESTCHESTER COUNTY LABORATORIES AND RESEARCH ■ "Vi-! n\;c( iHi 2 Dana Road, Valhalla, New York 10595 T (914)231-1620 Fax (914) 231-1772 I® /•NYS-ELAP No. 10108 Time/Date Set: // Form A-70 (rev. 10/01)

Sample Type < 1. Potable 3. Non Potable Treated Bottle #'s:

, 2. Non Potable 4. Other _ Chain of Custody? Yes No Time/Date Collected:, __ L-Ci_____ _________ Comments: Collected By:___ /___ _ _____ , ' Agency Code: __?■ \ PWS #:: Source ID: Type Descriptor:

Collected From. BUI to:

Location's/lndividual's Name / Name/Company „

Street_____________________ : Street________ _

City/St/Zip_________________ : City/St/Zip:

Identification of Source______ : Phone#:: Fax#: J Collection Point: I CA,CH, Bi?.. Check#; Amount$,„

BACTERIO! OGiCAl ANALYSIS Lab#:: Lab#:___________________________: ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE'SOLID ANALYSIS __ Heterotrophic Plate Count Purgeable Halocarbons (624/8260) __ Trihalomethanes (524) (hemodialysis & aii oShers) __ Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) __ Volatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) __ Coliform MPN (priv well, raw, sip) __ Fecal Coliform (ail samples) __ Total Trihalomethane Potential (510) __ Organochiorine Pesticides (608/8081) __ Microscopic __ Microextractables (504) PCB's (Arochlors) (608/8081) __ Macroscopic Pesticides/PCB screen (508) . Herbicides (SM18/6630,8151) __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SM18/6630) API __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) __ Other:________________________I __ Pesticides (525) __ Glycols in Water Refrigerated?yes___ no __ Carbamate Pesticides (531) Acid Extractables (625/8270) __ Glyphosate (547) _ Base Neutral Extractables (625/8270) Chlorinated:?yes no _ Diquat (549) Jrr 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) . UCMR List 1 Jllli MtBE Only (524) RADIOCHLMSCAi. ANALYSIS ___,Radon „ Other____ __________________ ,

INORGANIC ANALYSIS REQUESTED -1 .k __ Color ___ Aridity __ Aluminum __ Potassium Turbidity ___ Alkalinity __ Antimony __ Selenium pH __ Bromide __ Arsenic __ Silver __ Conductivity __ Brornate/Chlorate/Chlorite __ Barium ■ __ Corrosivity (temp:. »C)i „ Chloride __ Beryllium __ Sodium ___ Thallium ___ BOD (5 day) __ Cyanide __ Vanadium Carbonaceous BOD (5 day) ___ Fluoride __ Cadmium _ Zinc „ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCO,; MB __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca-2 Metals/CN BII __ Dissolved Oxygen __ Nitrogen, Nitrate as N __ Chromium, Total Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Semi-violatiles li Total Organic Halides __ Nitrogen, Total Kjeldahl as N ___ Cobalt __ Pesticides/PCB’s _ _ Solids. Percent {%) __ Oil and Grease __ Copper ■I „ Solids, Settleable __ Phenol __ Iron TCL.P 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 TCLf^-Volatiles __ Other:: _ UV254 __ Molybdenum n;L>-4WVs __ Nickel

NYC-WTC_000074219