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 a 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 ■X

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; j 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/Zlp Identification of Source Phone#;_______ Fax#; Collection Point CA,CH. Bl? Check#: Amounts

BACTERIOLOGICAL ANALYSIS Lab#:_____________________ Lab#: OSiby- ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count ^:^Trihalomethanes (524) (hemodialysis & all others) __ Purgeable Halocarbons (624/8260) -^Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) J^^olatile Aromatics (524) __ Coliform MPN (priv well, raw, stp) __ Acrolein & Acrylonitrile (8260) __ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081) gs __ Microscopic __ Microextractables (504) _ PCB’s (Arochlors) (608/8081) __ Pesticides/PCB screen (508) _ Herbicides (SMI 8/6630,8151) sx __ Macroscopic 5»- __ PCB as Decachiorobiphenyl (508A) _ Other Pesticides (SMI8/6630) CO _ API __ Other:_____________________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-1.3) _ Pesticides (525) __ Glycols in Water Refrigerated?yes___ no __ ; Carbamate Pesticides (531) _ Acid Extractables (625/8270) '!> Chlorinated;?___ yes no __ Glyphosate (547) __ Bass Neutral Extractables (625/8270) _ Diquat (549) __ GC/MS Unknown Scan Free Chlorine Res:mg/L __ Chlorination Disinfection Byproducts (551) LU _ Phthalates (606MS) Total Chlorine Res;mg/L __ Haloacetic Acids (552) __ Other:___________ __ Other Pesticides (SMI8/6630) pH __________ _UCMRList1 RADIOCHEMICAL ANALYSIS _MtBE Only (524) __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: c5 __ Color __ Acidity __ Aluminum __ Potassiur i __ Turbidity __ Alkalinity __ Antimony __ Selenium cn _ pH __ Bromide O' __ 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 CaCOa __ Calcium, as CaCOs __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca^^ __ Dissolved Oxygen __ Nitrogen, Nitrate as N __ Chromium, Total _ Metals/CN __ Total Organic Carbon __ Volatiles __ 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 __ Solids, Total _TCLP-Metals __ Phosphorus, Ortho as P __ Magnesium __ Solids, Total Dissolved _TCLP-Pesticides __ Sulfates __ Manganese _ Solids, Total Volatile _TCLP-Herbicides __ Surfactants __ Mercury _ TCLP-Yolatiles __ Other:____ _____________ _ UV254 __ Molybdenum _ TCLP-BNA’s _ Nickel

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