Chain of Custody Record, Westchester County Lab, Mar 2002

NYC 9/11 Public Portal Document IK ACCn ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 4:a (914)231-1620 Fax (914) 231-1772 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: X) « X- Comments: Collected By; Agency Code: PWS #;________ Source ID: Type Descriptor: Collected From: Bill to: Location's/Individual’s Name Name/Company Street _________________ Street_________ City/St/Zip______________ City/SVZip Identification of Source Phone#;_______ Fax#: Collection Point (9 Z-S^ CA,CH, Bl? Check#: Amounts

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:_______________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count jiSTrihalomethanes (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) 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 (SMI8/6630,8151) _ API __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SM18/6630) __ Other:_____________________ _ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) __ Pesticides (525) __ Glycols in Water a Refrigerated? yes no __ : Carbamate Pesticides (531) _ Acid Extractables (625/8270) I 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 (SM18/6630) pH __________ _UCMRList1 RADIOCHEMICAL ANALYSIS _MtBE Only (524) __ Radon __ _Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Acidity __ Aluminum __ Potassium __ Turbidity ___ Alkalinity __ Antimony __ Selenium c? -L _ pH __ Bromide __ Arsenic __ Silver I co __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium Ci- __ 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 CaCOs __ Calcium, as CaCOs __ Chemical Oxygen Demand CLP / __ Nitrogen, Ammonia as N __ Calcium, Ca*^ __ Dissolved Oxygen __ Nitrogen, Nitrate as N __ Chromium, Total _ MelSIs/CN __ Total Organic Carbon __ Volatiles __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Total Organic Halides __ Semi-violatiles __ Nitrogen, Total Kjeldahl as N __ Cobalt __ Pesticides/PCB's __ Solids, Percent (%) __ Oil and Grease __ Copper __ Solids, Settleable __ Phenol __ Iron __ Solids, Suspended __ Phosphorus Total as P ICLP __ Lead __ 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 __ TCLP-BNA’s __ Nickel

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