Chain of Custody Record, Westchester County Lab, Mar 2002

NYC 9/11 Public Portal Document ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM •Wfestchester WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914) 231-1620 Fax (914) 231-1772 3

NYS-ELAPNo. 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: | Agency Code: PWS #;________ Source ID: Type Descriptor; Collected From: Bill to: Location’s/lndividual’s Name Name/Company _ Street __ _______________ Street_________ City/St/Zip______________ City/SUZip Identification of Source Phone#;_______ Fax#: Collection Point CA.CH, Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS Lab#;_______________________ Lab#; 09^ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count v^fTrihalomethanes (524) (hemodialysis & all others) __ Purgeable Halocarbons (624/8260) 2:^VolatiIe Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) ^XVoIatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) __ Coliform MPN (priv well, raw, stp) __ 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 (SM18/6630,8151) _ API __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SMI 8/6630) __ Other:_____________________ _ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) __ Pesticides (525) __ Glycols in Water Refrigerated?yes no __ Carbamate Pesticides (531) _ Acid Extractables (625/8270) g =c Chlorinated;?yes___ no __ Glyphosate (547) __ Base Neutral Extractables (625/8270) I __ Diquat (549) __ GC/MS Unknown Scan j:? Free Chlorine Res:mg/L __ Chlorination Disinfection Byproducts (551) _ Phthalates (606MS) > Total Chlorine Res;mg/L __ Haloacetic Acids (552) __ Other:__________________________ _Other Pesticides (SMI8/6630) pH __________ __ UCMRListI UJ RADIOCHEMICAL ANALYSIS __ MtBE Only (524) __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Aoidity __ Aluminum __ Potassium __ Turbidity _ pH __ Alkalinity __ Bromide __ Antimony __ Arsenic __ Seleniurrs __ Silver L S L. __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodiurn^ CO -o __ Corrosivity (temp;. “C) __ Chloride __ Beryllium _ Thalliunp -< Jsr _ BOD (5 day) __ Cyanide __ Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Zinc I _ Soluble BOD (5 day) __ Hardness. Total as CaCOa __ Calcium, as CaCOs CLP j __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*2 __ Dissolved Oxygen _ MetalsKN __ Nitrogen, Nitrate as N __ 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 __ Solids, Suspended __ Phosphorus Total as P __ Lead ISLE __ Solids, Total _TCLP-Wetals __ Phosphorus, Ortho as P __ Magnesium __ TCLP- Pesticides __ Solids. Total Dissolved __ Sulfates __ Manganese _TCLP-Herbicides __ Solids, Total Volatile __ Surfactants __ Mercury __ Other:_________________ __ TCLP-Volatiles _ UV254 __ Molybdenum _ TCLP-BNA's __ Nickel

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