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Laboratory and Radlatiol- <br />8100 Lowry Boulevard, I <br />US Mail: PO Box 17123, System ID ENV-200900098 <br />(303) 692-3090 fax (30 <br />^ orrV-K Ham Collection Date 1/ 1 /2009 8:30:OOAM <br />md EWAr0rAWVt Control Number 73 <br />REQUEST FOR ANALYTIC t;ooecnm rim <br />n. CUSTOMER SAMPLE I • • M• • <br />Customert0 Collected. / Time: 3 am. OUU -?' Name : monlfr day year <br />how min ? P.M. <br />Address : Collected by: Matrix <br />r-i ??: W C] Surface Water <br />Con <br />? Ground Water <br />hone: tact: i P -3s?> ? Treated Water <br />rr- SAMPLE SITE • <br />PWS ID: ?I Purpose : ? Routine ? Special Purpose ? Repeat <br />Sample Location: Description: Chlorine residual: Qa a MG/L Temp, Water: r][ ]F <br />g Address: Comments: <br />? Civ. St Zip. <br />TEST ORDER (Che ck appropriate box) <br />CHEMISTRY - INORGANIC CHEMISTRY - ORGANIC RADIOCHEMISTRY <br />? AWArmily, Phenolphthalein ? Molybdenum ? Carbamates ? Alpha/Bete. Gross <br />? Alkalinity, Total ? Mckei ? VOC ? Americium <br />-El-Aluminum - - -- p-Nitrogerk-Ammonia-Dist. - -O --l} m- - - - - - -?-Cartioi -l4- - - - - <br />O Antimony O Nitrogen, Keklatd ? BTEX ? Gamma Screen <br />? Arsenic ? 'Nitrogen, Total' ? DIQUAT Gamma Spectrometry, <br />e <br />O Barum O Ndate/Nkdte ? SOC <br />? Beryllium ? Nitribe ? SVOC ? Leak Test <br />? BOO ? pH ? Pestiades p Plutonium <br />? Boron ? Phosphate, Ortho ? Gyphosate .p, Radium 226 <br />? Cadmium ? Phosphate, Total p Herbicides ? Radium 228/ <br />p Calcium ? Potassium ? EDBIDBCP ?..Radon <br />? Chloride ? Selenium ? PCB ? Thorium <br />? Chlorine, total residual ? Silicon (silicates) ? ? Tritium !: <br />O <br />h <br />? Chromium ? <br />& t <br />er <br />? <br />? Conductivity ? silver ? G e) <br />M( ? Other. <br />? Sodium ? <br />? Copper ? solids, Dissolved <br />? Corrosiv" Vol <br />? Other <br />MICROBIOLOGY <br />? C hide, Dist (/k) ? Solids, Suspended <br />? uadds ? Solids, Total ? Total Coldborns, PA <br />? Hardness, total ? Sulfate Phase 1,2,5 -ANALYSES ? Total Cordonns, MTF <br />? Iron ? Thallium ? Heterotrophic Plate Count <br />I:3 Lead ? Uranium ? Organic (SOC I VOC) ? Pseudomonas MPN <br />? Magnesium ? Zinc ? Inorganic ? E. Cori., MPN <br />p Manganese ? Other ? Other. <br />0 Mercury ? Other n Other. <br />i I ? Cr . <br />LARS Internet Address: http://www.cdphe.state.co.usArArhom.htm o <br />RopoA rrzsax n RAv 12MIN <br />r?