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 2 Dana Road. Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 NYS-ELAPNo. 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; | fiLH ______ Agency Code: PWS #;________ Source ID: Type Descriptor: Collected From: Bill to; Location's/lndividual’s Name Name/Company Street_________________ Street_________ City/St/Zip______________ City/Sl/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 _i<rrihalomethanes (524) (hemodialysis & ail others) __ Purgeable Halocarbons (624/8260) 2^ Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, sip) 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) __ Macroscopic __ Pesticides/PCB screen (508) _ Herbicides (SM18/6630,8151) XX7 _ API __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SMI8/6630) i

__ Other:_____________________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) _ Pesticides (525) __ Glycols in Wafer 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 (SMI8/6630) pH ___________ _UCMRList1 RADIOCHEMICAL ANALYSIS _MtBE Only (524) __ Radon __ Other____________________ C J

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Acidity ___ Aluminum __ Potassiur i cn __ Turbidity __ Alkalinity __ Antimony __ Selenium _ pH __ Bromide __ Arsenic __ Silver __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium __ Corrosivity (temp: .’C) __ Chloride __ Beryllium __ Thallium _ BOD (5 day) __ Cyanide __ Boron __ Vanadiun i __ 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*2 __ Dissolved Oxygen __ Nitrogen, Nitrate as N _ Metals/CN __ Chromium, Total __ Total Organic Carbon __ Volatiles __ Nitrogen, Nitrite as N ___Chromium, Hexavalent __ Total Organic Halides __ Semi-violatiles __ Nitrogen, Total Kjeldahl as N __ Cobalt __ Solids, Percent (%) __ Pesticides/PCB's __ Oil and Grease __ Copper __ Solids, Seltleable __ Phenol __ Iron __ Solids, Suspended __ Phosphorus Total as P __ Lead I£LP __ Solids, Total _TCLP-Metals __ Phosphorus, Ortho as P __ Magnesium __ Solids, Total Dissolved __ TCLP-Pesticides __ Sulfates __ Manganese __ Solids, Total Volatile __ TCLP-Herbicides __ Surfactants __ Mercury __ Other;_________________ __ Molybd^um _ TCLP-Volatiles „ UV254 _ TCLP-BNA’s __ Nickel

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