Chain of custody record, Sample AE04125, Feb 2002

NYC 9/11 Public Portal Document

if ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH ."'IB/ ■v z TAA OHL ■

2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914)231-1772 L 1'7 i/n0b.ci ■ NYS-ELAP No. 10108 Time/Date Set? Form A-70 (rev. 10/01)

Sample Type (circle one): 1. Potable 3. Non Potable Treated I J li ■In Bottle #'s:____ ;__ _ i Si

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

Time/Date Collected:___________ _ _______ _ ■■llllll Comments. i - ■ . - -B

Collectec' " Agency Code: PWS #: . Source ID; Type Descriptor:

Collected From: Bill to: I Location’s/lndividual's Name__: Narne/Compariy

Street_______________________ Street: oil City/St/Zip__________________ : City/St/Zip Bl fln Identification of Source______ : Phone#: Fax#:

/pi Collection Point _ _______ S__ CA,CH, Bl? Check#: .j . Amount$; If ill bACTERiOLOGICAS ANALYSIS Lab#:.

I Lab#:__________________________ , __ Heterotrophic Plate Count ORGANIC POTABLE: ANALYSIS __ Trihaiomeihanes (524) ORGANIC NONPOTABLE/ SOLID ANALYSIS __ Purgeable Halocarbons (624/8260)

■ (hemodialysis & ail others) Coliform P/A (Public supplies) __ Volatile Halocarbons (524) Purgeable Aromatics (624/8260)

■ Mi __ Coliform MPN (priv well, raw, sip): __ Fecal Coliform (all samples) Microscopic __ Volatile Aromatics (524) __ Total Trihalomethane Potential (510) __ Microextractabies (504) __ Acrolein & Acrylonitrile (8260) __ OrganochlorinexPesticides (608/8081) __ PCB’s (Arochlors) (608/8081) __ Pesticides/PCB screen (508) __ Herbicides (SM18/6630.8151) B Macroscopic __ PCB as Decachlorobiphenyi (508A) _ Other Pesticides (SM18/6630) __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) __ other:______________________ _ Oli __ Pesticides (525) __ Glycols in Water ■ Refrigerated?yes___ no Chlorinated:?yes no __ Carbamate Pesticides (531) __ Glyphosate (547) Acid Extraclables (625/8270) _ Base Neutral Extractables (625/8270) __ Diquat (549) _^--GC/IVlS Unknown Scan Free Chlorine Res mg/L __ Chlorination Disinfection Byproducts (55 -) __ Phthalates (606MS) __ Haloacetic Acids (552) __ Other:_______________________________ K Total Chlorine Res:mg/Li __ Other Pesticides (SMI8/6630) L UCMR List 1 RADIOCHEMICAL ANALYSIS ...... MtBE Only (524) .....Radon .... Other J ..... -........:

F' 111 INORGANIC ANALYSIS REQUESTED - : a:.# __ Color __ Acidity Aluminum lilllBlOlBllillll

__ Potassium Hi Turbidity __ Alkalinity: __ Antimony Selenium ■ pH Conductivity __ Bromide __ Bromate/Chiorate/Chlorite __ Arsenic Barium Jii'Silver __ Sodium -■ __ Corrosivity (temp:) .."C) __ Chloride _j..-Beryllium Thallium _ BOD (5 day) __ Boron Ol _ Carbonaceous BOD (5 day) __ Cyanide __ Fluoride __ Cadmium __ Vanadium _2': Zinc __ Soluble BOD (5 day) __ Hardness. Total as CaCOa __ Calcium, as CaCOs CLP __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca« __ Metals/CN Dissolved Oxygen __ Nitrogen, Nitrate as N .^Chromium, Total ■ __ Total Organic Carbon __ Total Organic Halides __ Nitrogen, Nitrite as N __ Nitrogen, Total Kjeldahl as Ni __ Chromium. Hexavalent . 'Cobalt „. Volatiles __ Semi-violatiles . Pestfcides/PCB's __ Solids, Percent (%) __ Solids, Settleable __ Solids, Suspended __ Oil and Grease __ Phenol __ Phosphorus Total as P ooper tclp _ TCLP-Metals ■ Solids, Total __ Phosphorus, Ortho as P __ Magnesium ■I __ Solids, Total Dissolved __ Sulfates __ Manganese TCLP-Pesticides __ TCLP-Herbicides Solids, Total Volatile Surfactants -.'Mercury IB Other:__ _________________ _ UV254 Molybdenum __ TCLP-Volatiles TCLP-BNA's ... Nickel WH

NYC-WTC_000074226