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 (914)231-1620 Fax (914) 231-1772 NYS-ELAPNo. 10108 Time/Date Set: Form A-70 (rev. 10/01)

Sample Type (circle one): ^pPotable 3. Non Potable Treated Bottle #'s: 2. Non Potable 4. Other______ Chain of Custody? Yes___ No Time/Date Collected: JLlXlpex. 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/St/Zip Identification of Source Phone#;______ Fax#; Collection Point -------------- rCA,CH, Bl? 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) .jxVolatile 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 (SM18/6630,8151) __ PCB as Decachlorobiphenyl (508A) __ API __ Other:_____________________ __ Herbicides (515) __ Other Pesticides (SMI8/6630) __ Petroleum Hydrocarbon Scan (310-13) I __ Pesticides (525) __ Glycols in Waler s Refrigerated?yes__ _ no Chlorinated:?yes___ no Free Chlorine Res:mg/L __ Carbamate Pesticides (531) __ Glyphosate (547) __ Diquat (549) __ Chlorination Disinfection Byproducts (551) _ Acid Extractables (625/8270) __ Base Neutral Extractables (625/8270) __ GC/MS Unknown Scan __ Phthalates (606MS) r Total Chlorine Res:mg/L __ Haloacetic Acids (552) __ Other;__________________________ „ Other Pesticides (SM18/6630) pH _ __________ „UCMRList1 RADIOCHEMICAL ANALYSIS __MIBE Only (524) __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Aridity __ Aluminum __ Potassium __ Turbidity __ Alkalinity __ Antimony __ SelerJum _ pH __ Bromide ___Arsenic — Silve/ " __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Corrosivity (temp: ’C) __ Chloride __ Beryllium __ Thaflium^y _ BOD (5 day) __ Cyanide __ Boron __ Varsdium / __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium Zir^ _ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOa __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*^ __ Dissolved Oxygen __ Nitrogen, Nitrate as N _ Mbtals/CN __ Chromium, Total _ V61atiles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Semi-violatiles __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N __ Cobalt __ Solids. Percent {%) __ Pesticices/PCB’s __ Oil and Grease __ Copper __ Solids, Settleable __ Phenol __ Iron __ Solids, Suspended TCLP __ Phosphorus Total as P __ Lead __ Solids, Total _TCLP-IVIetals __ 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

NYC-WTC_000074788