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

NYC 9/11 Public Portal Document •<

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914) 231-1620 Fax (914) 231-1772 < (JujElMHMaMj X /'/filYS-ELAP No. 10108 Time/Date Set; . FonnA-70(rev.10/01)

^ple Type (circle one): S/’otable 3. Non Potable Treated Bottle#'s: 2. Non Potable 4. Other________________________ Chain of Custody?___ Yes No Time/Date Collected: Comments: Collected By:. U Agency Code: PWS#:______ Source ID: .Type Descriptor: Collected From: Bill to: Location’s/lndividuai's Name Name/Company Street_________________________ Street_______ ’)■ •

City/St/ap______________ ,_______ City/St/Zip Identification of Source Phone#: Fax#: Collection Point / 4 jU I CA,CH,BI? Check#: .Amounts.

I BACTERIOLOGICAL ANALYSIS Lab#:_____________________ _ Heterotrophic. Plate Count Lab#: ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOUD ANALYSIS __ Trihalome.thanes (524) _ Purgeable Halocarbons (624/8260) (hemodlal^is & all others) __ Coliform P/A (Public supplies) _ Volatile Halocarbons (524) _ Purgeable Aromatics (624/8260) _ _Coliform MPN (priv well, raw, stp) _ Volatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) _ Fecal Coliform (all samples) __ Total Trihalomethane-Potential (510) _ Organochlorine Pesticides (608/8081)

s _ Microscopic __ Microextractables (504) _ PCB’s (Arochlors) (608/8081) _ Macroscopic __ PestIcides/PCB screen (508) _ Herbicides (SM18/6630,8151) _API __ PCB as Decachlorobiphenyl (508A) >^ _ Othor Pesticides (SM18/6630) _Other: _ Herbicides (515) T__ Petroleum Hydrocarbon Scan (310-13) __ Pesticides (525) _ Glycols In Water Refrigerated?yes no __ Carbamate Pesticides (531) . Add Extractebles (625/8270) Chlorinated:?yes no _ Glyphosate (547) : " Base Neutral Extractables (625/8270) _Diquat (549) S^^/MS Unknown Scan Free Chlorine Res:___ j^mS/L _ Chlorination Disinfection Byproducts (551) OPhthaiates (606MS) Total Chlorine Res:__ 1 rng/L _Haloacetic Acids (552) ■ i-i ■ Other ‘ 'f _Other Pesticides (SM18/6630) - 2^ pH _UCMRList1 RADIOCHEMICAL ANALYSIS _MtBE Only (524) _Radon _ Other__________________

INORGANIC ANALYSIS REQUESTED - Lab#: _

I _ Color _ Turbidity _ pH ;_ (Conductivity _ Acidity __ Alkalinity __ Bromide __ Bromate/Chlorate/Chlorite Aluminum _E,Antimony ..^Arsenic Barium __ Potassium Selenium JZ Silver _ Sodium __ Corrosivity (temp:_____ “C) _ Chloride _L_ Beryllium J/Thallium _ BOD (5 day) __ Cyanide __ Boron __ vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium tZ Zinc _ Soluble BOD (5 day) j __ Hardness, Total as CaCOs _ Calcium, as CaCOs _ _Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*2 sEe __ Dissolved Oxygen _Metals/CN __ Nitrogen, Nitrate as N J/Chromium, Total _ Total Organic Carbon __ Nitrogen, Nitrite as N _ Volatiles __ Chromium, Hexavalent _ Seml-violatlles IFt __ Total Organic Halides _ Solids, Percent (%) _ Solids, Settleabie' __ Nitrogen, Total Kjeldahl as N __ Oil and Grease __ Phenol _k. Cobalt. X Copper iZIron _ Pestlcldes/PCB’s

__ Solids, Suspended ■_ Phosphorus Total as P ■•jc Lead.';'. ICLE _TCLP-IVIetaIs __ Solids, Total __ Phosphorus, Ortho as P __ Magnesium _TCLP-P8Sticides

r __ Solids, Total Dissolved _ Solids, Total Volatile yL Other_____ ZJZ_______ __ Sulfates __ Surfactants _ UV254 Manganese _L. Mercury _/.Molybdmum _TCLP-Herbicides _ TCLP-Volatiles _TCLP-8NA’s

i; NYC-WTC_000074603 i Nickel