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. 10/01)

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/Individual's Name Name/Company Street _________________ Street_________ City/St/Zip______________ City/St/Zip Identification of Source Phone#;_______ Fax#: Collection Point rT> -------------- I CA,CH, BI? Check#; Amounts.

BACTERIOLOGICAL ANALYSIS Lab#; Lab#;_______________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/ SOLID ANALYSIS __ Heterotrophic Plate Count .i^rihalomethanes (524) (hemodialysis & all others) __ Purgeable Halocarbons (624/8260) jrfVolatile 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 __ Peslicides/PCB screen (508) _ Herbicides (SM18/6630,8151) __ API __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SMI8/6630) __ Other;___________________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) __ Pesticides (525) __ Glycols in Water Refrigerated?yes no __ Carbamate Pesticides (531) _ Acid Extractables (625/8270) f Chlorinated;?yes no __ Glyphosate (547) __ Base Neutral Extractables (625/8270) X- __ 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 ---------------- __ UCMRListI RADIOCHEMICAL ANALYSIS __ MtBE Only (524) __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Acidity __ Aluminum __ Potas^iurr __ Turbidity __ Alkalinity __ Antimony __ Selen^i^ _ pH __ Bromide __ Arsenic __ Silver/ MP -O __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodium __ Corrosivity (temp: .“C) __ Chloride ’ __ Beryllium __ Thallium _ BOD (5 day) __ Cyanide __ Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium __ Zin^ _ 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 __ Chromium, Total __ Metals/CN __ Total Organic Carbon __ Volatiles __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Total Organic Halides __ Semi-violatiles __ Nitrogen, Total Kjeldahl as N __ Cobalt __ Solids, Percent (%) __ Pesticides/PCB's __ Oil and Grease __ Copper __ Solids, Settieable __ Phenol __ Iron TCLP __ Solids, Suspended __ Phosphorus Total as P __ Lead __ Solids, Total _TCLP-Metals __ Phosphorus, Ortho as P __ Magnesium __ Solids, Total Dissolved __ TCLP-Pesticides __ Sulfates __ Manganese _ Solids, Total Volatile __ TCLP- Herbicides __ Surfactants __ Mercury _ TCLP-Volatiles __ Other: _ _______________ _ UV254 __Molybdenum _ TCLP-BNA's __ Nickel

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