Chain of Custody Record, Westchester County Lab, Mar 2002

NYC 9/11 Public Portal Document I , _ vs ACCc 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) ’ t P Sarnple Type (circle one): /V ■! / Q. Potable 3. Non Potable Treated Bottle #’s:

2. Non Potable 4. Other Chain of Custody? Yes No / Comments: Time/Date Collected: Collected By: v.. »■ '' " ’ Agency Code: PWS #:________ Source ID: Type Descriptor: Collected From: Bill to: Location’s/lndividual's Name J Name/Company Street_________________ _ Street < City/St/Zip______________ City/St/Zip Identification of Source Phone#:_______ Fax#: J. Collection Point CA.CH, Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS Lab#: I Lab#: __ ____________________ ORGANIC NONPOTABLE/SOLID ANALYSIS ORGANIC POTABLE ANALYSIS __ Heterotrophic Plate Count __ Trihalomethanes (524) __ Purgeable Halocarbons (624/8260) (hemodialysis & all others) __ Volatile Halocarbons (524) __ Purgeable Aromatics (624/8260) s' __ 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) __ Pesticides/PCB screen (508) _ Herbicides (SM18/6630,8151)

I __ Macroscopic __ PCB as Decachlorobiphenyl (508A) _ Other'Pesticides (SM18/6630) _ API __ Other:__________ __________ __ Herbicides (515) __ Petroleum Hydrocarbon Scan (310-13) __ 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) 3C/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 _________ __ _UCMR List 1 RADIOCHEMICAL ANALYSIS _MtBEOnly (524)^ __ Radon I __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: ;_ Color __ Acidity Aluminum __ Potassium __ Turbidity __ Alkalinity v-Antimonv j:L(Selenium, — pH __ Bromide Jv'Arsenic Silver __ Conductivity __Bromate/Chlorate/Chlorite V Barium __ Sodium __ Corrosivity (temp:. .’C) __ Chloride _h‘Beryllium Thallium _ BOD (5 day) __ Cyanide __ Boron _ Vanadium __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium- Zinc _ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOa CLP __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N- __ Calcium, Ca*2 . Metals/CN .__ Dissolved Oxygen __ Nitrogen, Nitrate as N ^Chromium, Total _ Volatiles __ Total Organic Carbon __ Nitrogen, Nitrite as N __ Chromium, Hexavalent __ Semi-violatiles __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N _j. Cobalt __ Pesticides/PCB's __ Solids, Percent (%) __ Oil and Grease __ Copper __ Solids, Settleable __ Phenol _ Iron ICLP ___ Solids, Suspended __ Phosphorus Total as P t Lead __ TCLP-Metals __ Solids, Total __ Phosphorus, Ortho as P __ Magnesium I_ TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates __ Manganese __ TCLP-Herbicides __ Solids, Total.Volatile __ Surfactants __ Mercury " TCLP-Volatiles

f. j-f'Other: v* /■___________ UV254 __ Molybdenum I_ TCLP-BNA’s ' Nickel

NYC-WTC_000074930