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P .n <br />Svstem ID ENV-2009004=479 <br />Collection Date 5/5/2009 10:30:00AM <br />Control Number 57 <br /> CUSTOMER <br /> SAMPLE IN FORMATION <br /> C <br />Name: , coneaed Tom' U :. a <br />0 pm <br /> <br /> <br />Address : J month day year . <br />hour min <br />' <br /> City/SYZp: i 3 ?3S 1t' l S? - -, Collected by.. Mat rw <br /> <br />A contact <br />t O Surface Water <br /> : S Kyq\ <br />Phu ? Ground Water <br />? ? Treated Water <br /> SAMPLE SITE COMMENT S - <br /> PWS la: <br /> Purpose: ? Routine ? Special Purpose ? Repeat <br /> Sample location: <br /> <br />Description: <br />Chlorine residual. as FID MGIL <br />Temp- Water: F <br />[][] <br />x <br />g Address: CGi Comments: <br />k1d, Crty sr zip. <br />TEST ORDER (Che ck appropriate box): Use ON <br />CHEMISTRY- INORGANIC CHEMISTRY- ORGANIC RADIOCHEMISTRY <br />? Alkalinity, Phenolphthalein ? Molybdenum ? Carbamates ? Alpha/Beta, Gross <br />? Alkalinity, Total ? Nickel VOC O Americium <br />_O Alum _ _ ? NI" is Dist_ . <br /> <br />Antrnwn "AqWn IQe hl . _ TkiM_ <br /> <br />? <br />--p-Carbon-14 - <br />O Gamma Screen <br />? Arsenic <br /> <br />,Total y <br />WNW <br /> <br />n% T <br /> <br />Gamma Spectrometry, <br />O Barium ? N'drate/Nk to ? S ? Nuclide Specific <br />? Beryllium ? Nitrite O SVOC ? Leak Test <br />O BOD ? pH O Pesticides ? Plutonium <br />? Boron O Phosphate, Ortho ? Glyphosate .O, Radium 226 <br />? Cadmium ? Phosphate. Total ? Herbicides ? Radium 228 <br />O Calcium ? Potassium ? EDBIDBCP ? .Radon <br />? Chloride O Selenium ? PCB ? Thorium <br />? Chlorine, total residual O Silicon (silicates) ? TOC ? Tritium <br />Q Chromium ? DRO ? Other. <br />? Conductivity ? Solver ? HEM (On Grease) ? Other. <br />? Copper ? Sodium ? Other . <br />O rd temp.) O Solids, Dissolved O Other <br />MICROBIOLOGY <br /> <br />t5 Solids, Suspended <br />snide, Dist. <br />? Fluoride 0 Solids, Total ? Total Conforms, PA <br />O Hardness, total 0 SuKate Phase 1,2,5 -ANALYSES ? Total Conforms, MTF <br />O Iron ? Thafum ? Heterotrophic Plate Count <br />0 Lead ? Uranium ? Organic (SOC / VOC) ? Pseudomonas MPN <br />? Magnesium O Zinc ? Inorganic ? E. Con., MPN <br />? Manganese O Other O Other <br />C; Mercury O Other. .0 Other. <br /> <br />LARS Intemet Address: http://www.odphe.state.co.us/ir/lrhom.htm ' <br />Repot 025DPK Rw 12MIN <br />REQUEST a„. nnnnnnnn