Chain of Custody Record, Westchester County Lab, Mar 2002

NYC 9/11 Public Portal Document ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM Westchester 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): ^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/Individual’s Name, Name/Company Street __________________ Street________ City/St/Zip______________ City/St/Zip Identification of Source Phone#; Fax#; Collection Point ------------------------- rCA.CH, Bl? Check#; Amounts.

BACTERIOLOGICAL ANALYSIS Lab#: Lab#;_______________________ ORG, IC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count J^n'rihalomethanes (524) (hemodialysis & all others) __ Purgeable Halocartjons (624/8260) _Y;^olatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, sip) r::<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) 33- __ Macroscopic __ Pesticides/PCB screen (508) _ Herbicides (SiVI18/6630,8151) _ 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) 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:__________________________ _ Other Pesticides (SM18/6630) pH ___________ __ UCMRListI RADIOCHEMICAL ANALYSIS _MtBE Only (524) __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: CD -O __ Color __ Acidity __ Aluminum __ Potassiun -< o- __ Turbidity _ Alkalinity __ Antimony __ Selenium U-J _ pH __ Bromide __ Arsenic __ Silver __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium / __ Corrosivity (temp: “C) __ Chloride __ Beryllium __ Thallium _ BOD (5 day) __ Cyanide __ Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Zinc __ Soluble BOD (5 day) __ Hardness, Total as CaCOs __ Calcium, as CaCOs __ Chemical Oxygen Demand CLP __ Nitrogen, Ammonia as N __ Calcium, Ca*^ __ Dissolved Oxygen _ Metals/CN __ Nitrogen, Nitrate as N __ Chromium, Total __ Total Organic Carbon __ Volatiles __ Nitrogen, Nitrile as N __ Chromium, Hexavalent __ Total Organic Halides __ Semi-violaliles __ Nitrogen, Total Kjeldahl as N __ Cobalt __ Solids, Percent (%) __ Pesticides/PCB's __ Oil and Grease __ Copper __ Solids, Settleable __ Phenol .__ Iron __ Solids, Suspended __ Phosphorus Total as P __ Lead I£LE __ Solids, Total _TCLP-Wetals __ Phosphorus, Ortho as P __ Magnesium __ Solids, Total Dissolved __ TCLP-Pesticides __ Sulfates __ Manganese __ Solids, Total Volatile __TCLP-Herbicides __ Surfactants __ Mercury __ Other:__ ______________ _TCLP-\/olatiles _ UV254 __ Molybdenum _ TCLP-BNA's __ Nickel

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