Chain of Custody Record, Westchester County Lab, Mar 2002

NYC 9/11 Public Portal Document AOCojj ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH id X 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): 0 Potable 3. Non Potable Treated Bottle #'s: 2. Non Potable 4. Other____________ Chain of Custody? Yes No ■Hme/Date Collected: Comments: Collected By; Rpi 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 v^rihalomethanes (524) (hemodialysis & all others) __ Purgeable Halocarbons (624/8260) 2^Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) :s<VoIatile 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 Extractables (625/8270) __ Glyphosate (547) J no __ Base Neutral Extractables (625/8270) Chlorinated:?yes _ Diquat (549) __ GC/MS Unknown Scan x:- 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#; I _ _ Color __ Acidity __ Aluminum __ Potassium __ Turbidity __ Alkalinity __ Antimony __ Selenium/ O _ pH __ Bromide __ Arsenic __ Silver I __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium -o __ Sodium I ■<

__ Corrosivity (temp: .’C) __ Chloride __ Beryllium cn __ Thalliunj _ BOD (5 day) __ Cyanide __ Boron __ Vanadiu^ c? __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Zinc _ Soluble BOD (5 day) __ Hardness. Total as CaCOs __ Calcium, as CaCOs __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca’-^ GLE i __ Dissolved Oxygen __ MetalsfcN __ Nitrogen, Nitrate as N __ Chromium, Total __ Total Organic Carbon __ Nitrogen, Nitrite as N _ Chromium, Hexavalent _ Volatiles __ Total Organic Halides __ Semi-violatiles __ Nitrogen, Total Kjeldahl as N __ Cobalt __ Solids, Percent {%) __ Oil and Grease __ Pesticides/PCB’s __ Copper __ Solids, Settleable __ Phenol __ .Iron i __ Solids, Suspended TCLP __ Phosphorus Total as P __ Lead __ Solids, Total _TCLP-lMetals __ Phosphorus. Ortho as P __ Magnesium __ Solids, Total Dissolved __ TCLP-Pesticides __ Sulfates __ Manganese __ Solids, Total Volatile __ TCLP-Herbicides __ Surfactants __ Mercury __ Other:_________________ __ TCLP-Volatiles _ UV254 __ Molybdenum _ TCLP-BNA's _ Nickel

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