Chain of Custody Record, Westchester County Lab, Mar 2002

NYC 9/11 Public Portal Document tK 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 4 9

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: 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, Bl? Check#; Amounts

BACTERIOLOGICAL ANALYSIS Lab#; Lab#;_______________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/ SOLID ANALYSIS __ Heterotrophic Plate Count ySTrihalomethanes (524) (hemodialysis & all others) __ Purgeable Halocarbons (624/8260) Volatile Halocarbons (524) __ Purgeable Aromatics (824/8260) __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, sip) i^ifVoIatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) __ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) __ Organochlorine Pesticides (608/80B1) __ 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) ,1 __ 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) I __ Diquat (549) __ GC/MS Unknown Scan i:- 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 U-' RADIOCHEMICAL ANALYSIS _MtBE Only (524) __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Acidity __ Aluminum __ Potassium __ Turbidity __ Alkalinity __ Antimony __ Selenium _ pH __ Bromide __ Arsenic __ Silver h. O __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodiuni^ __ Corrosivity (temp: .“C) __ Chloride __ Beryllium __ Thalliup _ BOD (5 day) __ Cyanide __ Boron __ Vanad ium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Zinc / _ Soluble BOD (5 day) ___Hardness, Total as CaCOa __ Calcium, as CaCOa __ Chemical Oxygen Demand CLP 1 __ Nitrogen, Ammonia as N __ Calcium, Ca*^ __ Dissolved Oxygen __ Nitrogen, Nitrate as N _ Metafs/CN __ Chromium, Total __ Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N __ Semi-violatiles __ Cobalt __ Solids, Percent (%) _ Pesticides/PCB's ___Oil and Grease __ Copper __ Solids, Settleable __ Phenol __ Iron TCLP __ Solids, Suspended __ Phosphorus Total as P __ Lead __ Solids, Total _TCLP-fMetals __ Phosphorus, Ortho as P __ Magnesium __ Solids, Total Dissolved _TCLP-Pesticides __ Sulfates __ Manganese __ Solids, Total Volatile _TCLP-Herbicides __ Surfactants __ Mercury __ Other. _ ________________ _ TCLP-Volatiles _ UV254 __ Motytxienum __ TCLP-BNA’s __ Nickel

NYC-WTC_000074787