Chain of Custody Record, Westchester County Lab, Mar 2002

NYC 9/11 Public Portal Document tit ACCn ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM -AVe^tchester 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): ^Potable 3. Non Potable Treated Bottle #’s: 2. Non Potable 4. Other Chain of Custody?___ Yes___ No Time/Date Collected:______ __________________ Comments: Collected By: f 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 a --------------- CA,CH, Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS Lab#: Lab#:_______________________ ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS __ Heterotrophic Plate Count _2<lrihalomethanes (524) (hemodialysis & all others) __ Purgeable Halocarbons (624/8260) _i--V^atiIe Halocarbons (524) __ Purgeable Aromatics (624/8260) __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, sip) _K:^olatiIe 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) __ API __ PCB as Decachlorobiphenyl (508A) _ Other Pesticides (SM18/6630) __ Herbicides (515) __ Petroleum Hydrocarbon Scan (31O-1;^--- __ Other:_____________________ __ Pesticides (525) __ Glycols in Water Refrigerated?yes___ no __ ; Carbamate Pesticides (531) _ Acid Extractables (625/8270) __ Glyphosate (547) __ Base Neutral Extractables (625/8270)7 Chlorinated:?yes____no __ 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 ___________ _UCMRList1 RADIOCHEMICAL ANALYSIS _MtBE Only (524) Cn Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Acidity __ Aluminum __ Potassium __ Turbidity __ Alkalinity __ Antimony __ Selenium a • __ Bromide _Sil^r _ pH __ Arsenic Conductivity __ Bromate/Chlorate/Chlorite __ Barium __ Scpium 03 -o __ Corrosivity (temp:. ."C) __ Chloride __ Beryllium __ Tnallium •*< j , _ BOD (5 day) __ Cyanide __ Boron __ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium _^nc _ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOs __ Chemical Oxygen Demand CLW __ Nitrogen, Ammonia as N __ Calcium, Ca*2 __ Dissolved Oxygen __ Nitrogen, Nitrate as N Metals/CN __ 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 __ Solids, Suspended __ Phosphorus Total as P __ Lead ISLE __ Solids, Total _TCLP-IMetals __ Phosphorus, Ortho as P __ Magnesium __ Solids, Total Dissolved __ TCLP-Pesticides __ Sulfates __ Manganese __ Solids, Total Volatile __ TCLP-Herbicides __ Surfactants __ Mercury __ Other. _ _______________ _ TCLP-Volatiles _ UV254 __ Molybdenum __ Nickel _ TCLP-BNAs

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