Chain of Custody Record, Westchester County Lab, Mar 2002

NYC 9/11 Public Portal Document ACCn 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): ^^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 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, BI? Check#; Amounts

BACTERIOLOGICAL ANALYSIS Lab#: Lab#;________________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count v<Trihalomethanes (524) (hemodialysis & all others) __ Purgeable Halocarbons (624/8260) "'Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) 2r:fVolatiIe 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 (SMI8/6630,8151) _ API __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SMI 8/6630) __ Other:_____________________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13)

Refrigerated?yes___ no Chlorinated:?yes no __ Pesticides (525) __ Carbamate Pesticides (531) __ Glyphosate (547) __ Glycols in Water _ Acid Extractables (625/8270) __ Base Neutral Extractables (625/8270) s _ 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 ___________ __ UCMRListI RADIOCHEMICAL ANALYSIS _MtBE Only (524) __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: I __ Color __ Acidity __ Aluminum _ Potassium __ Turbidity _ pH __ Alkalinity __ Bromide __ Antimony __ Arsenic __ Seleniu^ __ Silver S co .zr; __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __Sodiurr __ Corrosivity (temp:^“C) __ Chloride __ Beryllium _ Thallii •< o- _ BOD (5 day) __ Cyanide __Boron __ Vanac __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium Zinc j _ Soluble BOD (5 day) __ Hardness. Total as CaCOs __ Calcium, as CaCOs __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N ___Calcium, Ca*^ __ Dissolved Oxygen _ Met^s/CN __ Nitrogen, Nitrate as N __ Chromium, Total __ Total Organic Carbon __ Volaples __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Total Organic Halides __ Semi-vlolatiles __ 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 TCLP __ Solids, Total _TCLP-Metals __ Phosphorus, Ortho as P __ Magnesium __ Solids. Total Dissolved _TCLP-Pesticides __ Sulfates __ Manganese __ Solids. Total Volatile _TCLP-Herbicides __ Surfactants __ Mercury __ Other:_________________ _ TCLP-Volatiles _ UV254 __ Molybdenum __ TCLF-Bi'JA’s __ Nickel

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