Chain of custody form, NYC DEP sample AE04941, Mar 2002

NYC 9/11 Public Portal Document - 1 ‘rn ?■ .d ACC/i. ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES ANO RESEARCH 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 NYS-tLAP No. 10108 Time/Date Set: Fomi A-70 (rev.10/01) Z’ Sample Type (circle one): 1>Potable 3. Non Potable Treated Bottle #’s: _^^on Potable 4. Other Chain of Custody? Yes No Time/Date Collected:, Comments:.___ Agency Code/U PWS #:_______ Source tO: Type Descriptor: F. Collected By: _ Collected From: Bill to: Location’s/lndividuars Name fl Name/Company_ Street________________ Street________

Kf'. City/St/Zip_____________ Identification of Source Collection Point 2S5 City/Stap Phone#: _____ _Fax#:.

----- I CA,CH, Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:.____________________ ORGANIC POTABLE 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) .i. Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) — Organochlortne Pesticides (608/8081) __ Microscopic _ Microextractabies (504) — PCB’s (Arochlors) (608/8081) Macroscopic _ Pesticides/PCB screen (508) _ Herbicides (SM18/663O,8151) .3 API __ PCS as Decachlorobiphenyl (508A) — Other Pesticides (BM18/6630) _ Other:__________ :________ _ Herbicides (515) — Petroleum Hydrocarbon Scan (310-13) _ Pesticides (525) — Glycols in Water i Refrigerated?yes Chlorinated:?yes no no __ Carbamate Pesticides (531) __ Glyphosate (547) — Acid Extractables (625/8270) — Base Neutral Extractables (625/8270) _Diquat (549) ..-e><eC/MS Unknown Scan Free Chlorine Res: . rng/L _ Chlorination Disinfection Byproducts (551) — Phthalates (606MS) Total Chlorine Res: . mg/L __Haloacetic Acids (552) — '■ Other: ____

pH —-------------- _ Other Pesticides (SM18/6630) _UCMRList1 RADIOCHEMICAL ANALYSIS __MtBE Only (524) __Radon _Other -u-xx-i INORGANIC ANALYSIS REQUESTED -Lab#: _ f xSxx __ Color _ Acidity " ---------- - _Aluminum _. Potasslum ’ " __ Turbidity _ Alkalinity __ Antimony __ Selenium — pH : __ Bromide __ Arsenic _ Silver _ (Conductivity _ Bromate/Chlorate/Chlorite _ Barium __ Sodium __ Corrosivity (temp:. ’C) __ Chloride __ Beryllium — Thallium _ BOD (5 day) . __ Cyanide __ Boron „ Vanadium __ Carbonaceous BOD (5 day) _ Fluoride __ Cadmium _ .Zinc _ Soluble BOD (5 day) __ Hardness, Total as CaCOs _ Calcium, as CaCOs _ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*2 ICLE __ Dissolved Oxygen _ Nitrogen. Nitrate as N _Metals/CN __ Chromium, Total __ Total Organic (Carbon _ Nitrogen, Nitrite as N — Volatiles __ Chromium, Hexavalent — Semi-violatiles __ Total Organic Halides _ Nitrogen, Total Kjeldahl as N _ Cobalt __ Pesticides/PCB's __ Solids, Percent {%) __ Oil and Grease _Copper _ Solids, Settieable _ Phenol __ Iron __ Solids, Suspended __ Phosphorus Total as P — Lead ICtE _.TCLP-Metais _ Solids, Total __ Phosphorus, Ortho as P __ Magnesium _TCLP-Pestlcides _ Solids, Total Dissolved __ Sulfates __ Manganese _ Solids, Total Volatile _TCLP-Herbicides __ Surfactants __ Mercury _ Other: ___ ____________ _ UV254 _TCLP-Volatiles __ Molybdattan „TCLP-BNAs — Nickel

NYC-WTC_000074598