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System ID ORG-2008000106 <br />Laboratory Services Division Collection Date 7/7/2008 2:50:OOPM <br />4 a, 8100 Lowry Boulevard, Denver, CO 80230-6928 Control Number 30 <br />US Mail: PO Box 17123, Denver, CO 80217 <br />-? (303) 692-3090 fax (303) 344-9989 <br />Colorado Department <br />of Publicllealsts <br />and Envirorunent. <br />REQUEST FOR ANALYTICAL SERVICES <br />CustomerlD <br />Name: <br />Address <br />City/St/Zip <br />Phone : <br />Contact <br />Contact Phone <br />PWS ID: COO <br />Name: <br />Address: <br />Description: <br />WP013098 <br />Molen and Associates LLC <br />2090 East 104th #202 <br />Thornton Cc 80233 <br />303-450-1600 <br />Mark Molen <br />71071 -[1[1[1 <br />City <ouncy /a[a[e up <br />Location Source Point of location <br />Collection No: ? ? ? ? ? ? ? T <br />Collected: b ILalE TimeT® o?I a.m. <br />month day year our min <br />Received: 00_00 _ [111 Time[j] o []D <br />month da year hour min <br />Collected 'y: M Water Type: <br />Purpose: Wutine F-I Special Purpose E] Repeat <br />Chlorine residual:: n .00 m9/L Temp., Water 000C <br />Fluoride - [ <br />[TO <br />. <br />Temperature at Receipt: <br />I TEST ORDER (Check appropriate box): <br />CHEMISTRY-INORGANIC <br />? Alkalinity, Phenolpathalein ? Iron ? Solids, Total <br />? Alkalinity, Total ? Inorganic Mandatory ? Sulfate <br />? Aluminum (Phase I, II, V) ? Thallium <br />? Antimony 0 Lead <br />? Uranium <br />? Arsenic ? Lithium ? Zinc <br />? Arsenic III, total 13 Magnesium ? Other: <br />? Arsenic V, total <br />? Manganese <br />11 Barium ? Mercury <br />? Beryllium <br />? Molybdenum <br />? BOD ? Nickel <br />? Boron <br />? Automated Ammonia <br />? Cadmium ? Nitrogen, Kjeldahl <br />13 Calcium (Carbonate) ? Nitrogen, Total <br />? Chloride ? Nitrogen, Nitrate/Nitrite <br />11 Chlorine, Total residual 13 Nitrogen, Nitrite <br />? Chromium <br />? Nitrogen, Nitrate <br />? Chromium Hexavalent ? pH <br />? Conductivity ? Phosphate, Ortho <br />? Copper <br />? Phosphate, Total <br />? Corrosivity (Langlier) ? Potassium <br />? Cyanide, Distilled ? Selenium <br />? Cyanide, Direct <br />? Silicon (silicates) <br />13 Cyanide, WAD ? Silver <br />? Fluoride ? Sodium <br />El Hardness total ? Solids, Dissolved <br /> ? Solids', Suspended <br />CHEMISTRY-ORGANIC <br />? Phase 1, 2, 5 <br />? VOC (Regulated) <br />? SOC (Regulated) <br />? DBP (Regulated) <br />? VOC (Screen) <br />? SVOC (Screen) <br />? HEM (Oil & Grease) <br />? THM <br />? BTEX <br />? TOC <br />K Other: <br />? Other: <br />? Other: <br />? Other: <br />? Other: <br />? Other: <br />MICROBIOLOGY <br />? Total Coliforms, PA <br />? Total Coliforms, MTF <br />? Fecal Coliforms, MTF <br />? E.Coli., MPN <br />? Heterotrophic Plate Count <br />? Pseudomonas Culture <br />? Other: <br />? Other: <br />RADIOCHEMISTRY <br />? Alpha/Beta, Gross <br />? Americium <br />? Gamma Spectrometry, <br />Nuclide Specific <br />? Plutonium <br />? Radium 226 <br />? Radium 228 <br />? Radon <br />? Thorium <br />? Uranium <br />r ? Alpha/Beta, Gross <br />? Carbon-14 <br />? Ni-63 " <br />? H-3 <br />? Other: <br />? Other: <br />CPD <br />? VOC <br />? Fat + Preservatives In Meat :___ <br />? Water Activity <br />? Other: <br />6 <br />it)`! IL _Lf a " <br />DATE / TIME <br />RELINQUISHED BY: I DATE / TIME I RECEIVED BY: I DATE / TIME <br />LSD Interent Address: littp://www.cdphe.state.co.us/h-/Irliom.htm Report #250Req <br />? a.m. <br />? P.M.