Chain of Custody Record, Westchester County Lab, Mar 2002

NYC 9/11 Public Portal Document 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 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: Comments; ________ Collected By: I 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 S3 CA,CH, Bl? Check#: Amounts

BACTERIOLOGICAL ANALYSIS Lab#;_______________________ __ Heterotrophic Plate Count Lab#; MW ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS .t^Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) (hemodialysis & all others) js^Volatile 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 __ Pesticides/PCB screen (508) __ PCB as Decachlorobiphenyl {508A) _ Herbicides (SM18/6630.8151) _ Other Pesticides (SM18/6630) s _ API 1 __ Other:_____________________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13J' __ Pesticides (525) __ Glycols in Water Refrigerated?yes___ no __ ; Carbamate Pesticides (531) _ Acid Extractables (625/8270) i 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) cn Total Chlorine Res:mg/L _ Haloacetic Acids (552) __ Other;___________________________ _ Other Pesticides (SMI8/6630) pH ___________ __ UCMRLislI RADIOCHEMICAL ANALYSIS _MtBE Only (524) Radon __ _Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: I co __ Color __ Acidity __ Aluminum __ Potassium •< j , __ Turbidity __ Alkalinity __ Antimony __ Sele.liunv. . cr _ pH __ Bromide __ Arsenic _Siive __ Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Sodi im ' __ Corrosivity (temp:. .’C) __ Chloride __ Beryllium __ Thal ium _ BOD (5 day) __ Cyanide __ Boron __ Van; dium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium Zinq _ Soluble BOD (5 day) __ Hardness, Total as CaCO3 __ Calcium, as CaCOs __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*^ __ Dissolved Oxygen „ Metals/CN __ Nitrogen, Nitrate as N __ Chromium, Total __ 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, Settleable __ Phenol __ Iron TCLP __ Solids, Suspended __ Phosphorus Total as P __ Lead __ Solids, Total _TCLP-Metals __ Phosphorus, Ortho as P __ Magnesium __ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates __ Manganese __ Solids, Total Volatile __ TCLP-Herbicides __ Surfactants __ Mercury __ Other:_________________ _ TCLP-Volatiles _ UV254 __ Molybdenum _ TCLP-BNA’s __ Nickel

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