Chain of custody record, Sample AE04125, Feb 2002

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ALU Ml I: WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Oana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 NYS-ELAP No. 10108 Time/Date Set: Form A-70 (rev. 10/01)

Sample Typo - ; 1. Potable 3. Non Potable Treated Bottle #'s: _ ‘J CxL. ■ ■ ______ ___ _______ ' L-

2. Non Posable 4. Other Chain of Custody? Yes No Time/Date Collected: Comments: Collec' ' t- c : ,i Agency Code: _ PWS #:___________ Source ID: .Type Descriptor: Collected From: Bill to; / ' o '" ; ’ Location’s/lndividual’s Name Name/Company:

Street______________ _ Street j

City/St/Zip: City/St/Zip: identification of Source- Phone#:j _ Fax#: Collection Point: CA.CH, Bl? . Check#:: Amount$„

BACTERIOLOGICAL ANALYSIS Lab#: _ Lab#:__________________________ _ ORGANIC POIABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic 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 (ail samples) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides {608/8081) __ Microextractables (504) _ PCB’s (Arochlors) (608/8081) __ Microscopic __ Pesticides/PCB screen (508) — Herbicides (SM18/6630,8151) Macroscopic __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SM18/6630) — API __ Other:: Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13.) __ Pesticides (525) __ Glycols in Water Refrigerated?yes . no __ Carbamate Pesticides (531) — Acid Extractables (625/8270) Chlorinated:?yes- no Glyphosate (547) * — Base NeutcaLExtractabies (625/8270) __ Diquat (549) _.xrGC/MS Unknown Sc^ Free Chlorine Res: mg/L ___ Chlorination Disinfection Byproducts (551): __ Phlhaiales (: Total Chlorine Res;, - mg/L. __ Haloacetic Acids (552) __ Other:.______ Other Pesticides (SM18/6630) pH_____________ ..UCMRL:sti RADiOCHEMICAL ANALYSIS _ MtBE Only (524) __ .Radon __ Other_______________________ : ; ■ ■-/:

INORGANIC ANALYSIS REQUESTED -1 a;v;: __ Color __ Acidity __ Aluminum Potassium __ Turbidity __ Alkalinity __ Antimony __ Selenium pH __ Bromide __ Arsenic — Silver __ Conductivity __ Brornate/Chiorate/Chiorite Barium , Sodium _ Corrosivity (temp: "C): __ Chloride .Thallium _ BOD (5 day) __ Cyanide , Vanadium i __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium ■l . Zinc Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOs 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-violatiles __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N — Cobalt ... __ Pesbddes/PCB's __ Solids, Percent (%) __ Oil and Grease __ Copper __ Solids, Settieable __ Phenol Iron i 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-Volatiles - Other: : UV254 __ , Molybdenum TCLP-BNAs __ Nickel

NYC-WTC_000074224