Chain of Custody Record, Westchester County Lab, Mar 2002

NYC 9/11 Public Portal Document ACCo. 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-ELAP No. 10108 Time/Date Set- Form A-70 (rev.10/G1)

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: I Agency Code; PWS tf:________ Source ID: .Type Descriptor: Collected From: Bill to: Location’s/Individual’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 NONPOTABLB SOLID ANALYSIS __ Heterotrophic Plate Count li^Trihalomethanes (524) (hemodialysis & all others) __ Purgeable Halocarbons (624/8260) 2^olatile Halocarbons (524) __ Purgeable Aromatics (624/8260) & __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) ^::^-VoIatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) > __ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/8081 __ Microscopic __ Microextractables (504) _ PCB’s (Arochlors) (608/8031) __ Macroscopic __ Pesticides/PCB screen (508) _ Herbicides (SMI8/6630,8151) _ API __ PCB as Decachlorobiphenyl (508A) __ Other Pesticides (SM18/6630) __ Other;_____________________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-130.'j _ Pesticides (525) __ Glycols in Water cc 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) OP __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Acidity __ Aluminum __ Potassiurr __ Turbidity __ Alkalinity __ Antimony __ Selenium I _ 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 CLP __ Dissolved Oxygen __ Nitrogen, Nitrate as N _ Metals/CN __ Chromium, Total _ Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Semi-violatiles __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N __ Cobalt __ Solids, Percent (%) __ Pesticides/PCB's __ Oil and Grease __ Copper __ Solids, Settleable __Phenol __Iron I£LP __ Solids, Suspended __ Phosphorus Total as P __ Lead _TCLP-Metals __ Solids, Total __ 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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