Chain of Custody Record, Westchester County Lab, Mar 2002

NYC 9/11 Public Portal Document ACCn 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): ^^^otable 3. Non Potable Treated Bottle #’s: 2. Non Potable 4. Other Chain of Custody? Yes No Time/Date Collected:__ Comments: Collected By; T/SP 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_____________ PS L- r3A,CH, Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS Lab#; Lab#:_______________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count i^Trihalomethanes (524) (hemodialysis & all others) __ Purgeable Halocarbons (624/8260) ^*^olatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, sip) _:ifVolatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) , __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081 ki-' __ Fecal Coliform (all samples) __ Microscopic __ Microextractables (504) _ PCB’s (Arochlors) (608/8081) 3- __ Macroscopic __ Pesticides/PCB screen (508) _ Herbicides (SMI8/6630,8151) _ API __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SM18/6630) _ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-133 __ Other:_____________________ __ Pesticides (525) __ Glycols in Water Refrigerated?yes___ no __ .Carbamate Pesticides (531) _ Acid Extractables (625/8270) 3^" Chlorinated;?yes___ no __ Glyphosate (547) __ Base Neutral Extractables (625/8270)::^ __ Diquat (549) __ GC/MS Unknown Scan Free Chlorine Res:mg/L __ Chlorination Disinfection Byproducts (551) _ Phthalates (606MS) UJ

Total Chlorine Res:mg/L __ Haloacefic Acids (552) _ Other:_____________ __ Other Pesticides (SM18/6630) pH ___________ __UCIV1R List 1 RADIOCHEMICAL ANALYSIS _MtBE Only (524) __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: _ J . OP -.o __ Color __ Acidity __ Aluminum __ Potassium -< Oi __ Turbidity __ Alkalinity __ Antimony __ Selenium -C- _ pH __ Bromide __ Arsenic __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium __ Corrosivity (temp:. .’C) __ Chloride __ Beryllium _Thiliium / _ BOD (5 day) __ Cyanide __ Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Zi^c _ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOa __ __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca'"^ __ Dissolved Oxygen __ Nitrogen, Nitrate as N _ Metal s/CN __ Chromium, Total __ Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Semi-violatiles __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N __ Cobalt __ Pesticides/PCB’s __ Solids, Percent (%) __ Oil and Grease __ Copper __ Solids, Settleable __ Phenol __ Iron TCLP __ Solids, Suspended __ Phosphoojs Total as P __ Lead __ Solids, Total _TCLP-Metals __ Phosphorus, Ortho as P __ Magnesium __ Solids, Total Dissolved __ TCLP-Pesticides __ Sulfates __ Manganese __ Solids, Total Volatile __ TCLP-Herbicides __ Surfactants __ Mercury __ Other;_________________ _ TCLP-Volatiles __ UV254 __ Molybdenum _ TCLP-BNA's __ Nickel

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