Chain of Custody Record, Westchester County Lab, Mar 2002

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

Sample Type (circle one): fl. Potable 3. Non Potable Treated Bottle #’s: 2. Non Potable 4. Other____________ Chain of Custody?___ Yes No Time/Date Collected: Comments: ./J/L • ’ i Collected By: A ' V Agency Code: PWS #:-___ Source ID: .Type Descriptor: Collected From: Bill to: Location’s/lndividual's Name Name/Company Street_________________ Street________ I City/St/Zip______________ City/St/Zip Identification of Source Phone#: Fax#: < Collection Point CA,CH, Bl? Check#: ' Amounts

?: r BACTERIOLOGICAL ANALYSIS Lab#:______________________ _ __ Heterotrophic Plate Count Lab#:

ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) t (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) __ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081) __ Microscopic __ Microextractables (504) __ PCB's (Arochlors) (608/8081) __ Macroscopic __ Pesticides/PCB screen (508) __ Herbicides (SMI8/6630,8151) __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SMI 8/6630) /■ _ API __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) IS __ Other:_____________________ __ Pesticides (525) __ Glycols in Water i Sy' Refrigerated?yes no __ Carbamate Pesticides (531) __ Acid Extractables (625/8270) Chlorinated:? yes no __ Glyphosate (547) __ Base Neutral Extractables (625/8270) •I??- __ Diquat (549) _2-'‘GC/MS Unknown Scan Free Chlorine Res: . mg/L __ Chlorination Disinfection Byproducts (551) __ Phthalates (606MS) Total Chlorine Res: - mg/L __ Haloacetic Acids (552) __ Other: _________________________ __ Other Pesticides (SM18/6630) pH ___________ ---------- 7------------------------------------------------------------------------ _UCMR List1 RADIOCHEMICAL ANALYSIS __ MtBE Only (524)

r- __ Radon .__ Other____________________

INORGANIC ANALYSIS REQUESTED ■ Lab#: 1 __ Color __ Aridity .- - - Aluminum __ Potassium __ Turbidity __ Alkalinity Antimony _!,.-Selenium _ pH __ Bromide _ Arsenic _VSilver __ Conductivity __ Bromate/Chlorate/Chlorite 32 Barium __ Sodium

r; __ Corrosivity (temp:. _ BOD (5 day) __ Carbonaceous BOD (5 day) °C) __ Chloride __ Cyanide __ Fluoride Beryllium __ Boron __ Cadmium _21"Thallium __ Vanadium < jj'Zinc __ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOa "CLP I __ Chemical Oxygen Demand __ Dissolved Oxygen __ Nitrogen, Ammonia as N __ Nitrogen, Nitrate as N __ Calcium, Ca*2 _(2Chromium, Total _ Metals/CN

I __ Total Organic Carbon __ Total Organic Halides __ Solids, Percent (%) __ Nitrogen, Nitrite as N __ Nitrogen, Total Kjeldahl as N __ Oil and Grease __ Chromium, Hexavalent 3i'Cobalt i . Copper __ Volatiles __ Semi-violatiles _ Pesticides/PCB’s __ Solids, Settleable __ Phenol Ji'Iron TCLP __ Solids, Suspended __ Phosphorus Total as P __Lead __ TCLP-Metals __ Solids, Total _ Phosphorus, Ortho as P __ Magnesium _ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates _L. Manganese __ TCLP-Herbicides __ Solids, Total Volatile __ Surfactants _ .Mercury __ TCLP-Volatiles L- Other: ____________ _ UV254 __ Molybdenum I' _L TCLP-BNA’s _i_ Nickel

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