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- laboratory and Radiation Services Division <br />• 8100 Lowry Boulevard, Denver CO 80230928 <br />`~•n' US Mail: PO Box 17123, Denver CO 80217 <br />~~~~° ~ '~ (303) 692-3090 fax (303) 3q.4..gg89 <br />na ,~~ <br />.4 <br />REQUEST FOR ANALYTICAL SERVICE <br />CustomerlD <br />Name : $~}~ (~, <br />Address : l 3t' J~ `,S"~~ ~ 6L1.) <br />crty/st/rp. ~~'~ (~Q~~ m tC~fi. St ~ 2, l ~ <br />Contact: " ~ -7 ~ ~ (aj <br />Phone ~~3 ~ ~ G -~~~- <br />Pvvs ID: <br />Sample Location: <br />.~ D~Ptre s^ <br />/ Cdy. <br />ll~ <br />~ ZP= <br />System ID If10-2008001241 <br />Collection Date 3/27/2008 9:48:OGAM <br />Control Number 400 <br />Collected: <br />month day y <br />Collected by: <br />Tirane. I II G~, I • IU IIf~ .dam. <br />hJo~L mJm J ^ P.m. <br />Matroc_ I I <br />^ Surface Water <br />^ Ground Water <br />^ Treated Water <br />Purpose : ^ Routine ^ Special Purpose ^ Repeat <br />Chlorine n:sidual: I____I r. ^ ~ MG/L Temp., Water: ^ ^ F <br />Comments: <br />TEST ORDER (Che ck appropriate box) : ~ <br />CHEMISTRY- INORGANIC CHEMISTRY- ORGANIC RADIOCHEMISTRY <br />^ Alkalnity, Phenolphthalein ^ Molybdenum ~ ^ Carbamates ^ Alpha/Beta, Gross <br />^ Alkalinity, Total ^ Nidcet I ^ VOC <br />~ <br />^ Americium <br />^ Aluminum ^ Nitrogen, Ammonia Dist. ^ THM ^ Carbon-14 <br />^ Antunon <br />y ^ Nrtroyen, ICetdahl ^ BTEX ^ Gamma Screen <br />D Arsenic ^ 'Nitrogen, Total ^ DIQUAT Gamma Spectrometry, <br />^ Barium D Nitrate/Nitrite D SOC ^ NuGide Specfic <br />^ Beryllium ^ Nitrite ^ SVOC <br />D Leak Test <br />^ BOD ^ PH ~~ <br />^ Boron ~ P ^ Plutonium <br />^ Phosphate, Ohio G to ^ Radium 226 <br />^ Cadmium ^ Phosphate, Total ^ Herbu~des ^ Radium 228 <br />^ Cak3um <br />^ Potassium ^ EDB/DBCP <br />O .Radon <br />^ ~lo~ ^ Selenium ^ PCB ^ Thorium <br />^ Chlorine, total residual <br />^ Silicon (silicates) D TOC <br />^ Tritium <br />^ Chromium ~ ^ DRO ^ Other. <br />^ Sever <br />^ Conductivity ^ HEM (Oil Grease) ^ Other. <br />^ Copper ^ Sodium ^ Other. <br />^ Co ityrd temp.) ^ Solids, Dissolved <br />~ ^ Other <br /> <br />(`7 solids, suspended <br />C~~~'~ <br />~~___ _Di3 W ~( <br />MICROBIOLOGY <br />^ Fluoride ^ Solids, Total ^ Total Colifomu, PA <br />^ Hardness, total ^ Sulfate Phase 1 <br />2 <br />5 -ANALYSES ^ Total Coliforms, MTF <br />O Iron ^ Thallium , <br />, ^ Heterotrophic Plate Count <br />I.? Lead ^ Uranium ^ Orgariic (SOC / VOC) ^ Pseudomonas MPN <br />C Magnesium ^ Zinc ^ Inorganic ^ E. Coli., MPN <br />^ Manganese C Other: ^ Other. <br />[; Mercury ^ Other. , <br />i ~ ^ Other. <br /> <br />-ra <br /> <br />LARS Internet Address: http://www.cdphe.state.co.us/Ir/Ifiom.htm <br />rtep«r x~saxey, Rev ~tiot~s ''•~ <br />L6 <br />t~ <br />