Chain of Custody Record, Westchester County Lab, Feb 2002

NYC 9/11 Public Portal Document I

4 -' ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana 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 Type (circle one): 1. Potable 3. Non Potable Treated Bottle #’s: 5-' !4h 7 2. Non Potable 4. Other____________ Chain of Custody? Yes___ No Time/Date Collected: i • 1 . Jr Comments: Collected By: W Agency Code: PWS #:________ Source ID: Type Descriptor: Collected From: Bill to: Location's/lndividual's Name Name/Company Street_________________ Street_________ City/St/Zip' City/St/Zip Identification of Source Phone#:_______ Fax#: Collection Point 3 CA,CH,.BI? Check#: Amounts

BACTERIOLOGICAL ANALYSIS Lab#: Lab#: _ ______________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/ SOLID ANALYSIS __ Heterotrophic Plate’Count __ Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) (hemodialysis & all 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 Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081) __ Microscopic __ Microextractables (504) __ PCB’s (Arochlors) (608/8081) __ Macroscopic __ Pesticides/PCB screen (508) _ Herbicides (SM18/6630,8151) _ API __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SMI8/6630) A’; __ 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 Neutral Extractables (625/8270) _ Diquat (549) __ 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) pH _________ _ _UCMR List 1 RADIOCHEMICAL ANALYSIS _MtBEOnly (524) Radon ■__ Other____________________

e ■ INORGANIC ANALYSIS REQUESTED - Lab#: / ' i X r __ Color __ Turbidity __ Acidity __ Alkalinity Aluminum Antimony __ Potassium ’ ^Selenium — pH __ Bromide ^Arsenic _L; Silver \ __ Conductivity __ Bromate/Chlorate/Chlorite _Y Barium __ Sodium __ Corrosivity (temp:^’C) __ Chloride ^Beryllium _ Thallium .I _L BOD (5 day) __ Cyanide __ Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium c^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 J __ Total Organic Carbon __ Total Organic Halides __ Nitrogen, Nitrite as N __ Nitrogen, Total Kjeldahl as N __ Chromium, Hexavalent __ ^Cobalt __ Volatiles , __ Semi-violatiles __ Pesticides/PCB's __ Solids, Percent (%) __ Oil and Grease Copper __ Solids, Settleable _ Phenol Iron TCLP _ Solids, Suspended __ Phosphorus Total as P ^Lead _TCLP-Metals __ Solids, Total __ Phosphorus, Ortho as P __ Magnesium r __ .Solids, Total Dissolved __ Sulfates . Manganese __ TCLP-Pesticides __ TCLP-Herbicides e __ Solids, Total Volatile __ Other:_________________ __ Surfactants _ UV254 __ Mercury .• Molybdenum •• Nickel _ TCL P-Volatiles _ TCLP-BNA’s

NYC-WTC_000074368