Chain of Custody Record, Westchester County Lab, Mar 2002

NYC 9/11 Public Portal Document A-Co, ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ■ WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 uj a fl sjartj X (914) 231-1620 Fax (914) 231-1772 NYS-ELAP No. 10108 Time/Date Set: Form A-70 (rev. 10/01)

Sample Type {circle one): (i^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 Frdm: 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 ^Trihalomethanes (524) (hemodialysis & all others) __ Purgeable Halocarbons (624/8260) __ Coliform P/A (Public supplies) Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform MPN (priv well, raw. stp) j/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) __ Pesticides/PCB screen (508) 3a. __ Macroscopic __ Herbicides (SMI8/6630,8151) CO _ API __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SMI 8/6630) 1 __ 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) 77 __ Diquat (549) __ GC/MS Unknown Scan L.’.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 ___________ _UCMRList1 RADIOCHEMICAL ANALYSIS _MtBE Only (524) __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#; CD -O __ Color __ Acidity __ Aluminum __ Potass! jm “< cn __ Turbidity __ Alkalinity __ Antimony __ Seleniiiu-y __ ? _ pH __ Bromide __ Arsenic __ Silver __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium _ Sodiunt' __ Corrosivity (temp;. °C) __ Chloride __ Beryllium __ Thalliujn _ BOD (5 day) __ Cyanide __ Boron __ Vanadi jm __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium _Zinc __ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOs __ Chemical Oxygen Demand CLP __ Nitrogen, Ammonia as N __ Calcium, Ca*2 __ Dissolved Oxygen __ Nitrogen, Nitrate as N _ Metals/CN __ Chromium, Total __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Volatiles __ Chromium, Hexavalent __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N __ Semi-vioiatiles __ Cobalt __ Solids, Percent (%) __ Oil and Grease __ Pesticides/PCB’s __ 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 __ T CLP-Pesticides __ Sulfates __ Manganese __ Solids, Total Volatile __ TCLP-Herbicides __ Surfactants __ Mercury __ Other._________________ _ TCLP-Volatiles __ UV254 __ Molybdenum __ TCLP-BNA's Nickel

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