Chain of Custody Record, Westchester County Lab, Mar 2002

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

Sample Type (circle one): ^f^table 3. Non Potable Treated Bottle #’s: 2. Non Potable 4. Other Chain of Custody? Yes___ No Time/Date Collected:______ ___________________ Comments; Collected By: f Agency Code; PWS #:________ Source ID: Type Descriptor; Collected From: Bill to: Location's/Individual’s Name Name/Company _ Street __ _________ _ ____ Street_________ City/St/Zip______________ City/SUZip Identification of Source Phone#;_______ Fax#; Collection Point CA.CH. Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:_______________________ ORGANIC POTAIBLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count _ii4'rihalomethanes (524) (hemodialysis & all others) __ Purgeable Halocarbons (624/8260) .j^Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) & _tz^latile Aromatics (524) __ Acrolein & Acrylonitrile (8260) __ Coliform MPN (priv well, raw, stp) __ 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) I __ API __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SMI 8/6630) x: __ 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) __ Diquat (549) __ GC/MS Unknown Scan co Free Chlorine Res: .rng/L __ Chlorination Disinfection Byproducts (551) __ Phthalates (606MS) Total Chlorine Res: mg/L __ Haloacetic Acids (552) __ Other:__________________________ __ Other Pesticides (SMI 8/6630) pH ___________ __UCMRList1 RADIOCHEMICAL ANALYSIS __MtBE Only (524) __ Radon __ Other____________________ a — INORGANIC ANALYSIS REQUESTED ■ Lab#: _ _ Color __ Acidity __ Aluminum __ Potassium TT __ 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 __ Vanadium __ 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*2 Se ___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 __ Pesticides/PCB's __ Solids, Percent (%) __ Oil and Grease __ Copper __ Solids, Settleable __ Phenol __ Iron .TCLP __ Solids, Suspended __ Phosphorus Total as P __ Lead ___ Solids, Total _TCLP-Metals __ Phosphorus, Ortho as P __ Magnesium __ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates __ Manganese _TCLP-Herbicides __ Solids. Total Volatile __ Surfactants __ Mercury __ Other _________________ __TCLP-Volatiles _ UV254 __ Molybdenum __ TCLP-BNA's __ Nickel

NYC-WTC_000074795