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r`~ - laboratory and Radiation Services Division <br />• 8100 Lowry Boulevard, Denver CO 80230-6928 <br />US Mail: PO Box 17123, Denver CO 80217 <br />cameo (303) 692-3090 fax (303) 344-9989 <br />Orr~~1C r <br />N~ F#IIt10MM,~ <br />REQUEST OR A LYTICAL SERVICES <br />~ . - <br />Custanerl0 <br />-~' Nine : ~~Z1'~~1-~. <br />Address : 313 SN t'.I~.M Ip~ '.s1- '~.MV- ~ a,t $' <br />Contact $/t'YYt ~ }~ ~D~~ <br />Phone ' ~ $ ~ ~- Tl.)~ <br />~ . • <br />Pws 10: ~ ! 1 ^ ^ <br />System ID <br />Collection Date <br />Control Number <br />Collection No: <br />Collected: <br />Time: ~ ~~1 <br />month day Year hours min ^ P.m. <br />Collected by. Matrix: <br />Surface Water <br />^ Ground Water <br />^ Treated Water <br />Purpose : [Routine '^ Spedal Purpose ^ Repeat <br /> <br />Sample Location: r~(T- ~ ` (~ l ~ ~.~~_~~ N <br />_ LJ .i.1 .~ (S LK " `~T'C Chlorine residual: IJ a a ^ MG/L Temp, meter ^ ~ F <br />Address: ~~~' ~ ~ _ ~ ( ~~~ ~~'~ Comments: <br />4- ' <br />/ coy: t • ~ st: C„o zip: <br />LARS Internet Address: http://www.cdphe.state.co.us/Ir/Irhom.htm <br />Report ~250Req, Rev 1Ti01/99 <br /> TEST ORDER (Chec k appropriate box) : ~ <br />CHEMISTRY- INORGANIC CHEMISTRY- ORGANIC RADIOCHEMISTRY <br />^ Aficarinity, Phenolphthalein ^ Molybdenum ^ ~~~~ <br />^ AlphaBeta, Gross <br />p Alkarrnity, Total ^ Mdcel ^ VOC ^ Ameridum . <br />^ Aq~minum ^ Nitrogen, Ammonia Dist p THM ^ Carbon-14 <br />^ Antimony ^ Nitrogen, tCleklahl ^ BTIX ^ Gamma Screen <br />^ Arsenic ^ Nitrogen, Total ^ DiQUAT Gamma Spectrometry, <br />O Barium ^ NitratelNitrite ^ SOC adios Specific <br />^ ~~~ ^ Nitr~be ^ SVOC eak Test <br />^ BOD ^ pH ^ Pesticides ^ Plutonium <br />^ Boron ^ Phosphate, Ortho ^ GtYP~~ `~ p Radium 226 <br />^ Cadmium ^ Phosphate, Total ^ Herbiades ^ Radium 228 <br />^ Caktium ^ Potassium ^ EDB/DBCP p .Radon <br />^ Chbride ^ Selenium ^ PCB ^ Thorium <br />^ Chbrine, total residual ^ Silicon (silicates) ^ TOC ^ Tritium <br />^ Chromium ^ DRO ^ Other. <br />Q Conductivity ^ Sfiver ^ HEM (Or1 Grease) <br />^ Other. <br />^ Copper ^ Sodium ^ Other. <br />^ Comosiv'r reco ^ Solids. Dissolved <br />b Soros <br />suspended ^ Other. <br />MICROBIOLOGY <br />Cyanide, Dist <br />, <br />O Fluoride ^ Solids, Total ' <br />^ Total Corrfomu, PA <br />^ Hardness, total ^ Sulfate Phase 1,2,5 -ANALYSES ^ Total Corrfomu, MTF <br />^ Iron ^ ThalCum ^ Heterotrophic Plate Count <br />b Lead ^ Uranium ^ Organic (SOC / VOC) ^ Pseudomonas MPN Cm, <br />^ Magnesium ^ Zinc ^ Inorganic ^ E. Cofi., MPN <br />^ Manganese ^ ~~ ^ Other: ~ <br />[; Mercury ^ Other. ~ ^ Other. <br /> r;9 <br /> i <br />I s: <br /> <br />~ ~((~ 1~~ ~~s5 <br />INO-2008000180 <br />1 /912008 9:30:OOAM <br />101 <br />