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Laboratory Services Division
<br />8100 Lowry Boulevard, Denver, CO 80230-6928
<br />i r US Mail: PO Box 17123, Denver, CO 80217
<br />(303) 692-3090 fax (303) 344-9989
<br />Colorado 1.1»ent
<br />of Public Health
<br />and Environment
<br />REQUEST FOR ANALYTICAL SERVICES Collection No: ? a E E E E ? E
<br />• SPECIMEN INFORMATION
<br />CustomerlD : 00009830 EE [10 Time ?? a.m
<br />Collected: 1111
<br />Name : Department of Natural Resources -
<br />p.m
<br />Address : 1313 Sherman Street Room 215 month day year hour min
<br /> Collected by: Water Type:
<br />
<br />Denver CO 80203
<br />City/St/Zip
<br />Phone : 303-866-3567 Purpose: [-] Routine Special Purpose Repeat
<br />Email:
<br />Contact : Berhan Keffelow E Compliance F] Personal Information
<br />Fax:
<br />SAMPLE Chlorine residual: m9/L Water Temperature 00 °C
<br />PWS ID : coo ? ? F1 F1 [I ? _ ? ? ? Fluoride ?
<br />[][][] m
<br />/L
<br /> .
<br />g
<br />System Name:
<br /> Temperature at Receipt:
<br />Address: Comments:
<br />city County state LIP
<br />Description:
<br />Location Source
<br />[]Real Estate/HUD (Coliform Bacteria, COMPLIANCE DRINKING WATER TESTS Inorganic Parameters Organic Parameters
<br />Lead, Nitrate and Nitrite) Organic Chemicals Rule ?Alkalinity []Oil and Grease
<br />[]Annual Colorado Package OEDB/DBCP [] BOD OCBOD []DO ?VOCs Screen
<br />(Coliform Bacteria, Nitrate/Nitrite) []Chlorinated Pesticides []Chemical Oxygen Demand (COD) OSVOCS/Pesticide
<br />[]Expanded Annual Colorado []PCBs (Subcontracted) 0Chloride Screen
<br />Package (Coliform Bacteria, ?Chlorinated Herbicides 0Chlorine OBTEX
<br />Nitrate/ Nitrite, pH, TDS) []Volatile Organic Compounds (VOCs) 0Chromium, hexavalent (Cr's) Radiochemistr
<br />y
<br />[]General Colorado Package []Semivolatile Organic Compounds (SVOCs) OCorrosivity (Langlier) []Gross Alpha/Beta
<br />(Arsenic, Coliform Bacteria, Hardness, ?Carbamate Pesticides Cyanide ? Direct 0 Distilled []Radium 226
<br />Copper, Fluoride, Iron, Lead, ?Diquat (Subcontracted) ? WAD []Radium 228
<br />Nitrate/Nitrite, Uranium) DEndothall 0Fluoride []Uranium
<br />[]Deluxe Colorado Package []Glyphosate 0Hardness ?C-14
<br />(Alkalinity, Arsenic, Cadmium, Calcium, Inorganic Chemicals Rule []Mercury []Radon
<br />Coliform Bacteria, Chloride, []Primary Metals (Sb, As, Ba, Be, Cd, Cr, Hg, Individual Metals []Aluminum ONi-63
<br />Conductivity, Copper, Corrosivity, Ni, Se, Na TI) + Fluoride []Antimony []Arsenic []Barium []Gamma Spectromet
<br />Fluoride, Hardness, Iron, Lead, []Primary Metals (Sb, As, Ba, Be, Cd, Cr, Hg, []Beryllium []Cadmium []Calcium Specific Isotopes (list):
<br />Magnesium, Manganese, Ni, Se, Na TI) + Fluoride + Cyanide []Chromium []Cobalt []Copper
<br />Nitrate/ Nitrite, pH, Sodium, Sodium Nitrogen, []Nitrate ? Nitrite []Iron []Lead []Magnesium _
<br />Adsorption Ratio, Sulfate, Total Lead and Copper Rule []Manganese []Molybdenum Food Testing
<br />Dissolved Solids, Uranium, Zinc) []Lead and Copper []Nickel []Potassium []Selenium []Equilibrium pH
<br />[]Mining Baseline Package (pH, Radionuclides Rule []Silver []Sodium 0Strontium 0Starch
<br />Nitrate/ Nitrite, Aluminum, Arsenic, []Gross Alpha/Beta []Sulfur []Thallium []Tin []Fat
<br />Cadmiun, Copper, Iron, Lead, []Radium 226 []Tungsten []Uranium []Zinc ?WaterActivity
<br />Magnesium, Manganese, Potassium, []Radium 228 Nitrogen, []Ammonia Preservatives (list):
<br />Selenium, Sodium, Sulfur, Uranium, []Uranium [] Nitrate/Nitrite ? Total Kjeldahl _
<br />Sulfate, Gross Alpha/Beta) Disinfection Byproducts []Nitrate [] Nitrite _
<br />[]Mining Baseline Package without []Total Trihalomethanes (TTHMs) []pH []Mercury
<br />Gross Alpha/Beta OHaloacetic Acids (HAA5s) ? Phenol Metals (list):
<br />[]Drilling Baseline Package (Volatile ?Alkalinity Phosphorus
<br />Organic Compound Screen
<br />pH
<br />Total ?Bromate []Bromide ?Bromie []Phosphate, Ortho
<br />,
<br />,
<br />Dissolved Solids, Chloride, Fluoride, []Chlorate []Chlorite []Phosphate, Total []Bacteria in Food
<br />Alkalinity, Sulfate, Nitrate/Nitrite, Organic Carbon []Total 0 Dissolved []Sodium Adsorption Ratio Suspect:_
<br />Arsenic, Barium, Calcium, Chromium, []UV @ 254 Solids []Dissolved []Settleable Suspect:_
<br />Iron, Magnesium
<br />Selenium
<br />Sodium Total Coliform Rule Micr biolo /eac eria []Suspended []Total []Volatile Miscellaneous
<br />,
<br />,
<br />,
<br />Sulfur, and Uranium) []Total Coliform (Present/Absent, w/ E. coli) 0Specific Conductance []Soils/Filters -XRF
<br />[]Drilling Baseline Package without ?E. coli (Enumerated, w/ Total Coliform) 0Sulfate metals (list):
<br />VOC screen. []Total Coliform (Multiple Tube enumeration) []Sulfide
<br />[]Metals Scan: (Aluminum, Arsenic, ?Coliform, Fecal (Multiple Tube enumeration) []Turbidity
<br />Barium, Beryllium, Cadmium, Calcium, ?Heterotrophic Plate Count []Other Inorganic: []Unknown Substance
<br />Chromium
<br />Copper
<br />Iron
<br />Lead []Other Microbiology: Identification (FTIR)
<br />,
<br />,
<br />,
<br />,
<br />Magnesium
<br />Manganese
<br />Molybdenum
<br />,
<br />,
<br />,
<br />Nickel
<br />Potassium
<br />Selenium
<br />Silver
<br />,
<br />,
<br />,
<br />,
<br />Sodium, Uranium, Zinc
<br />CHAIN OF CUSTODY:
<br />RELINQUISHED BY: DATE/TIME: RECEIVED BY: DATE/TIME:
<br />RELINQUISHED BY: DATE/TIME: RECEIVED BY: DATE/TIME:
<br />RELINQUISHED BY: DATE/TIME: RECEIVED BY: DATE/TIME:
<br />LSD Interent Address: http://www.cdphe.state.co.us/Ir/lrhom.htm Report #250Req
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