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

NYC 9/11 Public Portal Document I I t ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH I 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)

r Sample Type (circle one): ■J Bottle #’s; J 1. Potable 3. Non Potable Treated ‘"2. Non Potable 4. Other_____________ Chain of Custody? Yes No Time/Date Collected: /// Comments: 1 Collected By: Y^ Agency Code: PWS #:_________ Source ID: Type Descriptor:

Collected From: Bill to:

Location’s/lndividual's Name Name/Company I • Street_______________ Street______ _ . City/St/Zip City/St/Zip Identification of Source Phone#; ’ Fax#: Collection Point a I CA,CH, Bl? Check#: Amount$.

BACTERIOLOGICAL ANALYSIS Lab#: Lab#;____________ ______________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count __ Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) (hemodialysis & alt others) __ Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliforrh P/A (Public supplies) __ 1 Coliform MPN (priv well, raw, stp) __ Volatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081) __ Fecal Coliform (all samples) __ Microscopic __ Microextractables (504) _ PCB’s (Arochlors) (608/8081) __ Macroscopic __ Pesticides/PCB screen (508) _ Herbicides (SMI8/6630,8151) __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SMI8/6630) — API __ Other: J_______________________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) t __ Pesticides (525) __ Glycols in Water Refrigerated?yes___ no __ Carbamate Pesticides (531) __ ■ Acid Extractables (625/8270) f. __ Glyphosate (547) __ Base Neutral Extractables (625/8270) ;.'S Chlorinated:? yes___ no __ Diquat (549) tXGC/MS Unknown Scan Free Chlorine Res:mg/L __ Chlorination Disinfection Byproducts (551) __ Phthalates (606MS) 1 J Total Chlorine Res:mg/L __ Haloacetic Acids (552) ___ Other:_______________i________________ __ Other Pesticides (SMI8/6630) I pH ___ __ UCMRListI . RADIOCHEMICAL ANALYSIS _MtBEOnly (524) ___ Radon Ik- ‘__ Other

INORGANIC ANALYSIS REQUESTED - Lab#;

I' __ Color ,__ Turbidity __ /'cidity , __ Alkalinity Aluminum Antimony 1 __ Potassium Selenium — pH __ Bromide Arsenic Silver Conductivity __ Bromate/Chlorate/Chlorite Barium __ Sodium __ Corrosivity (temp: °C) __ Chloride’ __t Beryllium _L_ 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 __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calciurh, Ca-^2 clF _ Metals/CN _ Dissolved Oxygen __ Nitrogen, Nitrate as N _2iChromium, Total __ Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Sem i-violatiles __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N c- Cobalt __ ..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 __ TCLP-Pesticides ' __ Solids, Total Dissolved __ Sulfates Manganese I __ .Solids, Total Volatile _ Surfactants Mercury __ TCLP,-Herbicides _ TCLP-Volatiles iZ- Other: -____________ __ UV254 _ Molybdenum _TCLP-BNAs ' '■' i _;i- Nickel &

NYC-WTC_000074669