Chain of Custody Record, Westchester County Lab, Mar 2002

NYC 9/11 Public Portal Document ACCo. 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: • Z-_________ Comments: Collected By:______ "bCrP / Agency Code: PWS #:________ Source ID: Type Descriptor: Collected From: Bill to; Location's/lndividuat's Name Name/Company Street________ ________ Street_________ City/St/Zip______________ City/Sf/Zip Identification of Source Phone#;_______ Fax#: Collection Point ----------------- I CA,CH, Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS Lab#:_______________________ Lab#: [?5lb>0 ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count JifTrihalomethanes (524) (hemodialysis & all others) __ Purgeable Halocarbons (624/8260) 2^rTVolatiIe Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) _s^olatile 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) Sfe __ Pesticides (525) __ Glycols in Water Refrigerated?yes no __ , Carbamate Pesticides (531) _ Acid Extractables (625/8270) 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) Total Chlorine Res: .mg/L _ _ Haloacetic Acids (552) __ Other TO _ Other Pesticides (SM18/6630) pH ___________ _UCMRList1 RADIOCHEMICAL ANALYSIS _ MtBE Only (524) __ Radon __ Other____________________

s J • ■ INORGANIC ANALYSIS REQUESTED - Lab#: I __ Color __ Acidity __ Aluminum __ Potass um __ Turbidity ■__ Alkalinity __ Antimony __ Selenium CX3 _ pH __ Bromide __ Arsenic __ Silver 07 __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodiu __ Corrosivity (temp: °C) ISO __ Chloride __ Beryllium __ Thallii _ BOD (5 day) __ Cyanide __Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Zinc f _ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOs __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*2 Sp f _ Melds/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 __ Pesticides/PCB’s __ Solids, Percent (%) __ Oil and Grease __ Copper __ Solids, Settieable __ Phenol __Iron ICLP __ 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 __ Other:_________________ __ TCLP-Volatiles _ UV254 __ Molybdenum _ TCLP-BNA’s __ Nickel

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