Chain of Custody Record, Westchester County Lab, Mar 2002

NYC 9/11 Public Portal Document iK ACen 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): ^^^otable 3. Non Potable Treated Bottle #'s; 2. Non Potable 4. Other Chain of Custody? Yes___ No Time/Date Collected: _ 6 2- 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 __ ____________ Cify/St/Zip Identification of Source Phone#;_______ Fax#; Collection Point CA.CH, Bl? Check#; Amounts

BACTERIOLOGICAL ANALYSIS Lab#; Lab#:_______________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLBSOLID ANALYSIS __ Heterotrophic Plate Count ,S:^rihaIomethanes (524) (hemodialysis & all others) __ Purgeable Halocarbons (624/8260) .^^^olatile Halocarbons (524) __ Purgeable Aromatics (624/8260) ■ __ Coliform P/A (Public supplies) l;<VoIatile 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) __ Pesticides/PCB screen (508) _ Herbicides (SM18/6630,8151) g __ Macroscopic __ API __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SMI8/6630) , __ Other:____________________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13)X;' __ 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 Free Chlorine Res; .mg/L __ Chlorination Disinfection Byproducts (551) _ Phthalates (606MS) Total Chlorine Res: - mg/L __ Haloacetic Acids (552) __ Other;_____________ __ Other Pesticides (SM18/6630) pH __________ __ UCMRListI RADIOCHEMICAL ANALYSIS _MtBE Only (524) Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: CD -o Color __ Acidity __ Aluminum __ Pl iiunT^ C5- ■ Turbidity __ Alkalinity __ Antimony __ Seleniumpy .... _ pH __ Bromide __ Arsenic _^ver pVM __ 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*^ __ Dissolved Oxygen __ Nitrogen, Nitrate as N __ Chromium. Total __ Metals/CN __ Total Organic Carbon __ Volatiles __ 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 __ Solids, Suspended ICLP __ Phosphorus Total as P __ Lead __ Solids, Total _TCLP-Wetals __ Phosphorus, Ortho as P __ Magnesium __ Solids. Total Dissolved __ TCLP-Pesticides __ Sulfates __ Manganese __ Solids. Total Volatile __TCLP-Herbicides __ Surfactants __ Mercury __ Other;_________________ _ TCLP-Y'olatiles _ UV254 __ Molybdenum _ TCLP-BNA’s __ Nickel

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