Chain of Custody Record, Westchester County Lab, Feb 2002

NYC 9/11 Public Portal Document r 1 ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 nA (914)231-1620 Fax (914) 231-1772 Z \\ NYS-ELAP No. 10108 Time/Date Set: L71 ■ . _ Form A-70 (rev. 10/01)

Sample Type4(ci.rcle one); 7, z-;(.> ') Bottle #’s:^^ K L 1. Potable 3. Non Potable Treated 2. Non Potable- 4. Other______ ._________________ Chain of Custody? Yes No V Ji -V 7 Time/Date Collected: - t i Comments: Collected By; Wb ( Agency Code:'. PWS #;________ Source ID: Type Descriptor: Collected From: Bill to: Location’s/lndividual’s Name Name/Company Street_________________ Street_________ City/St/Zip______________ Citv/St/Zio X-

Identification of Source Phone#:_______ Fax#: Collection Point I CA,CH, Bl? Check#: Amounts

Lab#: I BACTERIOLOGICAL ANALYSIS Lab#:____________ ___________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count (hemodialysis & all others) __ Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) __ Coliform,P/A (Public supplies) __ Volatile Halocarbons (524) JL Purgeable Aromatics (624/8260) __ Coliform MPN (priv well, raw, stp) __ Volatile Aromatics (524) j __ Acrolein & Acrylonitrile (8260) __ Fecal Coliform - (all samples) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081)' __ Microextractables (504) *■ _ PCB's (Arochlors) (608/8081) __ Microscopic __ Macroscopic __ Pesticides/PCB screen (508) __ Herbicides (SMI8/6630,8151) _ API __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SMI8/6630) __ 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:7 mg/L __ Haloacetic Acids (552) Other;. I _Other Pesticides (SMI8/6630) ‘ • pH ___________ _UCMRList 1 RADIOCHEMICAL ANALYSIS ■_MtBE Only (524) __ .Radon __ Other ______________ ______ I

INORGANIC ANALYSIS REQUESTED - Lab#: rib Color __ /Acidity ’::iC'Aluminum __ Potassium HI __ Turbidity __ Alkalinity Antimony sZ Selenium _ pH __ Bromide -/ -Arsenic -Z. Silver » Is __ Conductivity __ Bromate/Chlorate/Chlorite Barium __ Sodium I

Corrosivity (temp: .’G) __ Chloride I.. _ ^OD (5 day) __ Cyanide 'Z_ Beryllium __ Boron .Z_ Thallium __ Vanadium ,1

I".. Carbonaceous BOD (5 day) >._ Soluble BOD (5 day) __ Fluoride __ Hardness, Total as CaCOs __ Cadmium __ Calcium, as CaCOa / Zinc "CLP ~ __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*^ __ Dissolved Oxygen __ Nitrogen, Nitrate as N _Metals/CN ^"Chromium, Total __ Total Organic Carbon ' __ Volatiles __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Total Organic Halides __ Semi.^violatiles, __ Nitrogen, Total Kjeldahl as N ^Cobalt __ Solids, Percent (%) __ Pesticides/PCB’s __ Oil and Grease '•'"Copper !-■ __ Solids, Settleable __ Phenol ^'Iron tclp __ Solids, Suspended __ Phosphorus Total as P ' irl Lead ,__ Solids, Total _TCLP-Metals __ Phosphorus, Ortho as P __ Magnesium __ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates _i'''Manganese Solids, Total Volatile __ TCLP-Herbicides __ Surfactants ^Mercury __ TCLP-Volatiles' / Other;_______ _________ 1 UV254 <J_ Molybdenum __ Nickel _ TCLP-BNA’s

NYC-WTC_000074365