Chain of custody record, Sample AE04125, Feb 2002

NYC 9/11 Public Portal Document ■■

Stet' ENVIRONMENTAL SERVICES SAMPLE SUiSMiSSION FORM BIB I \.C( HIT WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914) 231-1620 Fax (914) 231-1772 liiSLSMS lllllt

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

r < / A? Sample Type (circle one)/ ■B^ot.i'-lc- 3. Non Pntohic Treated Bottle rs: BZ 2. Non Polable 4. Other Chain of Custody? j _ Yes No ^'nme/Date Collected:___ __________________ Cominentp; ---------- ----------------------------------- - Collected By: : Agency Code: PWS #:: Source ID: .'Type Descriptor: Collected From: Bill to-

Location’s/lndividual’s Name- Name/Company:

Street: Street j City/St/Zip_____________________________ i City/St/Zip: ■■ Identification of Source Phone#:: Fax#: ■ Collection Point_________ — CA,CH, Bl?: Check#: Amounts,

BACTERIOLOGICAL ANALYSIS Lab#:: Lab#:__________________________ ORGANIC POlABl.t ANALYSIS ORGANIC NONPOTABI.E/SOLID ANALYSIS __ Heterotrophic Plate Count __ Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) (hemodialysis & all others) __ Volatile Halocarbons (524) ,, Purgeable Aromatics (624/8260) __ Coilform P/A (Public supplies) __ Coliform MPN (priv well, raw, sip) __ Volatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) _ _ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) _ Organochlorine Pesticides (608/8081) __ Microscopic __ Microextractables (504) „ PCBs (Arochlors) (608/8081) Macroscopic __ Pesticides/PCB screen (508) _ Herbicides (SM18/6630.8151) __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides {SM18/6630) _... API __ Other:: __ Herbicides (515) ■■■I ___ Petroleum Hydrocarbon Scan (310-13) I __ Pesticides (525) ___ Glycols in Water Bl Refrigerated?yes; no: _ Carbamate Pesticides (531) _ Acid Exlractables (625/8270) Chlorinated:?yes. no Glyphosate (547) Neutral Extractables (625/8270) Diquat (549) JS^C/MS Unknown Scan 11 Free Chlorine Res:____ : mg/L __ Chlorination Disinfection Byproducts (551) ___ Phthalates (606MS) ■ iiiiillMI Total Chlorine Res:____ : mg/L: Haloacetic Acids (552) __ Other: Other Pesticides (SM18/6630) pH ..........

RADIOCHEMICAL ANALYSIS; _ UCMR List 1 MtBE Only (524) IIIH --------------------- ■ Radon __ Other_____________________ _ ■■■I ■III

■I INORGANIC ANA!.YSiS REQUESTED - Lab#: __ Color __ Turbidity __ Acidity Alkalinity :i-T— -i. Aluminum YL Antimony __ Potassium _J:Selenium — pH __ Bromide '* Arsenic JJ'Silver IB __ Conductivity __ Bromate/Chlorate/Chlorite Barium _ Sodium __ Corrosivity (temp: “C) __ Chloride IB Beryllium iJ Thallium I BOD (5 day) __ Cyanide __ Boron __ Vanadium ^Zinc __ Carbonaceous BOD (5 day) Fluoride __ Cadmium ■■■ __ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOs ## __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N _^.Calcium, Ca*2 __ Metals/CN __ Dissolved Oxygen __ Nitrogen, Nitrate as N j/Chromium, Ibtal __ Volatiles ■I __ 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 _L Iron III TCLP Solids, Suspended __ Phosphorus Total as P .-Bl 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-Volatiies J:1 Other:__ ^2________ : __ UV254 Ji Molybdenum _ TCLP-BNA's J:_ Nickel

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