Chain of custody record, Sample AE06580, March 2002

NYC 9/11 Public Portal Document

J ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM WESTCHESTER COUNTY LABORATORIES AND RESEARCH ' I *1* -V;' 2 Dana Road, Valhalla, New York 10595 (914) 231-1620 Fax (914) 231-1772 i NYS-ELAP No. 10108 Time/Date Set: I Form A-70 (rev. 10/01) id Sample Type (circle one): / 1. Potable 3. Non Potable Treated Bottle #'s: 2. Non Potable Time/Date Collected: 4. Other- Chain of Custody?___ Yes Comments: PWS #:______ Source ID- No 1 Type Descriptor: a- i Collected By: 1 . 1 Agency Code: Collected From: % Bill to: ii Location’s/lndividual’s Name Name/Company Street_________________ Street_______ City/St/Zip_____________ _ City/St/Zip Identification of Source Phone#: Fax#: Y: I 'P' Collection Point CA,CH, Bl? Check#: Amount$ I.

BACTERIOLOGICAL ANALYSIS Lab#: I Lab#:_______ ________________ __ Heterotrophic Plate Count (hemodialysis & all others) ORGANIC POTABLE ANALYSIS ' __ Trihalomethanes (524) ■ .A

__ Volatile Halocarbons (524) r ORGANIC NONPOTABLE/SOLID ANALYSIS __ Purgeable Halocarbons (624/8260) __ Purgeable Aromatics (624/8260) I' >; __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) __ Volatile Aromatics (524) __ Acrolein & Acrylonitrile (8260) •’v __ 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 (SMI8/6630) ’ ■ __ Other:_______ __ Herbicides (515) ;__ Pesticides (525) _ _ Petroleum Hydrocarbon Scan (310-13) __ Glycols in Water fl' Refrigerated? yes Chlorinated:? yes no no __ Carbamate Pesticides (531) __ Glyphosate (547) __ Diquat (549) __ Acid Extractables (625/8270) __ Base Neutral Extractables (625/8270) . GC/MS Unknown Scan 11 Free Chlorine Res: . mg/L Total Chlorine Res: . mg/L , .Chlorination Disinfection Byproducts (551) __ Haloacetic Acids (552) _ Phthalates (606MSj __ Other:_____ ______________________ o- pH ___________ __ Other Pesticides (SMI8/6630) _UCMRList1 ( S: RADIOCHEMICAL ANALYSIS _MtBEOnly (524) ■i'i __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ Acidity __ Aluminum Potassium __ Turbidity _ pH __ Alkalinity __ Bromide __ Antimony __ Arsenic __ Selenium _ Silver fl' __ Conductivity __ Corrosivity (temp:. °C) _ Bromate/Chlorate/Chlorite __ Chloride __ Barium __ Beryllium I. I J_ Sodiuni _ Thallium S’ _ BOD (5 day) __ Cyanide __ Boron Vanadium __ Carbonaceous BOD (5 day) _ Fluoride __ Cadmium __ Zinc __ Soluble BOD (5 day) ■

__ Hardness, Total as CaCOs __ Calcium, as CaCOa __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*2 S __ Dissolved Oxygen . Metals/CN ,__ Nitrogen, Nitrate as N __ Chromium, Total __ Total Organic Carbon Total Organic Halides . Solids,’Percent (%) __ Nitrogen, Nitrite as N __ Nitrogen, Total Kjeldahl as N __ Oil and Grease __ Chromium, Hexavalent __ Cobalt __ Copper __ Volatiles __ Semi-violatiles __ Pesticides/PCB’s 1 J _ Solids, Settleable __ Phenol __ Iron -S TCLP __ 'Solids, Suspended __ ; Phosphorus Total as P __ Lead _LTCLP-Metals __ Solids, Total __ Phosphorus, Ortho as P __ Magnesiufn _L TCLP-Pesticides __ Solids, Total Dissolved __ Sulfates __ Manganese __ Solids, Total Volatile _TCLP-Herbicides __ Surfactants __ Mercury _! TCLP-Volatiles __ Other:_________________ _ UV254 __ Molybdenum _ TCLP-BNA’s __ Nickel

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