Chain of custody record, Sample AE04125, Feb 2002

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM .•Slur WESTCHESTER COUNTY LABORATORIES AND RESEARCH! IB tAA'OU! 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 NY.S-ELAP No. 10108 Time/Date Set: Form A-70 (rev. 10/01)

Sample Type (circle one): ■ ■ l./Potable 3. Non Potable Treated Bottle #'s: ■.

2. Non Potable 4. Other_____________ : Chain of Custody?: Yes No ■

Time/Date Collected: CnPiinoiits- Collected By:______ : Agency Code: P-.7S _______ Source ID:Type Df/scriptor: Ccilected Frons: Bl'i to: ■ Location's/lndividual's Name: Name/Company Street_____ __ _______________________ j Street: "" '""■■’ip_____________________________________________ ! City/St'Zip Identification of Source: Phone#: Fax#:: Collection Point 1 I CACH. Ri'?: ■ Check#; _ ----------- ....------ Amounts

BACrERlOLOGICAl. ANALYSIS Lab#: H Lab#:__________________________ _ ORGANIC POTABLE ANALYSIS ORGANIC NONPO TABLE/SOLID ANAi.YSIS __ Heteroirophic Plate Count __ Trihalomethanes (524)- . Purgeable Halocarbons (624/8260) (hemodialysis & ail others) __ Volatile Halocarbons (524) Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) __ Volatile Aromatics (524) . Acrolein & Acrylonitrile (8260) __ Fecal Coliform (all samples) __ Total Trihaiomethane Potential (510) Organochlorine 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 (SM 18/6630) __ API __ Other:_______________________ _ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) __ Pesticides (525) __ Glycols in Waler ■II Refrigerated? yes no __ Carbamate Pesticides (531) __ Acid Extractables (625/8270)

I Chlorinated:? Free Chlorine Res:: yes no .. mg/L __ Glyphosate (547): _ Diquat (549) __ Chlorination Disinfection Byproducts (551) __ Base Neutral Extractables (625/8270) GC/MS Unknown Scan _ Phthalates (606MS)

■ Total Chlorine Res:, pH _____________ .. mg/L __ Haloacetic Acids (552) __ Other Pesticides (SM18/6630) _ Other:_______________________________

'011! _UCMRList1 RADIOCHEMICAL ANALYSIS _ MtBE Only (524) __ Radon _ Other: f-! Illi INORGANIC ANALYSIS REQUESTED -1 :.i A LAI 11 __ Color __ Acidity __ Aluminum __ Potassium Turbidity __ Alkalinity __ Antimony __ Selenium pH __ Bromide __ Arsenic __ Silver ■ JKli __ Conductivity __ Corrosivity (temp: /C) __ Bromate/Chlorate/Chlorite __ Chloride __ Bariu.m __ Beryllium __ Sodium __ Thallium BOD (5 day) Cyanide __ Boron __ Vanadium Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Zinc 11 __ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCO ■

■ __ Chemical Oxygen Demand __ Dissolved Oxygen __ Total Organic Carbon __ Nitrogen, Ammonia as N __ Nitrogen, Nitrate as N __ Nitrogen, Nitrite as N __ Calcium, Ca‘■2 __ Chromium, Total __ Chromium, Hexavalent _.Metals/CN __ Volatiles ■ Total Organic Halides __ Nitrogen, Total Kjeldahl as N: __ Cobalt __ Semi-violatiles Solids, Percent (%) __ Pesticides/PCB's __ Oil and Grease __ Copper

I11 __ Solids, Settleable __ Solids, Suspended __ Phenol Phosphorus Total as P __ iron __ Lead TCLp _TCLP-Metals __ Solids, Total __ Phosphorus, Ortho as P __ Magnesium 11 __ Solids, Total Dissolved __ Sulfates __ Manganese TCLP-Pesticides __ TCLP-Herbicides Solids, Total Volatile _ Surfactants __ Mercury ICiJ-'Vokiiiics _ Other: _____________ : _ UV254 Molybdenum 11 Nickel TCLP-BNA's

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