Chain of Custody Record, Westchester County Lab, Mar 2002

NYC 9/11 Public Portal Document 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-ELAPNo. 10108 Time/Date Set: Form A-70 (rev.10/01)

Sample Type (circle one): ^Potable 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/St/Zip Identification of Source Phone#:_______ Fax#: Collection Point______________ CA,CH, Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:_______________ _ ______ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count izfTrihalomethanes (524) (hemodialysis & all others) __ Purgeable Halocarbons (624/8260) v^olatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) ji^TVolatite 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 (SM18/6630.8151) _ API __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SM18/6630) __ Other: _ ________________ ___ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) _ Pesticides (525) __ Glycols in Water Refrigerated?yes no __ Carbamate Pesticides (531) __ Acid Extractabies (625/8270) A Chlorinated:?yes___ no __ Glyphosate (547) __ Base Neutral Extractabies (625/8270) __ Diquat (549) __ GC/MS Unknown Scan > Free Chlorine Res:mg/L __ Chlorination Disinfection Byproducts (551) _ Phthalates (606MS) Total Chlorine Res:mg/L __ Haloacetic Acids (552) __ Other:__________________________ 1.0 __ Other Pesticides (SMI8/6630) pH ____________ __ UCMRListI RADIOCHEMICAL ANALYSIS _ MtBE Only (524) __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: . cz __ Color __ Acidity __ Aluminum __ Potassiun o __ Turbidity _ pH __ Alkalinity __ Bromide __ Antimony __ Arsenic __ Seleniura __ Silver I 5 CJ-1 __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium! co __ Corrosivity (temp: “C) __ Chloride __ Beryllium _ Thalli un? _ BOD (5 day) __ Cyanide _ Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Zinc t _ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOs __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca+2 Se / __ Metals/CN __ Dissolved Oxygen __ 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 __ Solids, Percent (%) __ Pesticides/PCB's __ 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 _TCLP-Herbicides __ Solids, Total Volatile __ Surfactants __ Mercury _ TCLP-Volatiles __ Other:_________________ _ UV254 __ Molybdenum _ TCLP-BNA's __ Nickel

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