Chain of custody form, NYC DEP sample AE05050, Mar 2002

NYC 9/11 Public Portal Document ,1.

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). (j^Potable 3. Non Potable Treated Bottle #’s: ' 7 i. J -

2. Non Potable 4. Other Chain of Custody? Yes___ No

Time/Date Collected:________ Comments; Collected By:7,-' V ’ 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_________ 2 / CA.CH, Bl? Check#: Amounts

BACTERIOLOGICAL ANALYSIS Lab#: s Lab#:__________ ________________ ORGANIC POTABLE ANALYSIS ORGANIC NON POTABLE/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) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081) __ Fecal Coliform (all samples) __ Microextractables (504) _ PCB’s (Arochlors) (608/8081) __ Microscopic __ Pesticides/PCB screen (508) _ Herbicides (SMI8/6630,8151) __ Macroscopic __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SM18/6630) _ API __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) Other:____________________ __ Pesticides (525) __ Glycols in Water Refrigerated? yes no __ Carbamate Pesticides (531) __ Acid Extractables (625/8270) ft Chlorinated:? yes___ no __ Glyphosate (547) __ Diquat (549) __ ./Base Neutral Extractables (625/8270) Y GC/MS Unknown Scan Free Chlorine Res:mg/L __ Chlorination Disinfection Byproducts (551) _ Phthalates (606MS) Total Chlorine Res;mg/L __ Haloacetic Acids (552) Other; I I _ Other Pesticides (SMI8/6630) ■pH ---------------------- _UCMR List 1 ) pi , RADIOCHEMICAL ANALYSIS _MtBEOnly (524)

I" ' Radon _ Other-______________________

INORGANIC ANALYSIS REQUESTED - Lab#. ■__ Color __ ; Acidity _2-‘Aluminum ■/ Potassium ! _ 1 Turbidity __ Alkalinity _/ Antimony _/ Selenium __ Bromide _< Arsenic ft- — pH __ Conductivity __ Corrosivity (temp:. .°C) __ Bromate/Chlorate/Chlorite __ Chloride _v'Barium _^Beryllium _^Silver __ Sodium: _X Thallium __ .-BOD (5 day) __ Cyanide __ Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium / Zinc _ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOa CLP __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*2 _ Metals/CN __L Dissolved Oxygen __ Nitrogen, Nitrate as N J:^Chromium, Total __ Volatiles Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent _2'Cobalt __ Semi-violatiles

r & __ Total Organic Halides __ Solids, Percent (%) __ ■ Solids, Settleable __ Nitrogen, Total Kjeldahl as N __ Oil and Grease __ Phenol -'Copper r Iron __ Pesticides/PCB's

TCLP _L. Solids, Suspended __ Phosphorus Total as P __.Lead __ TCLP-Metals __ Solids, Total __ Phosphorus, Ortho as P __ Magnesium __ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates /Manganese __ TCLP-Herbicides __ Solids, Total Volatile __ Surfactants _L Mercury __ TC LP-Volatiles ( /other: ___JYXX_____ __ __ UV254 _/ Molybdenum _ TCLP-BNA’s ■ /Nickel

NYC-WTC_000074666