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r. -. Laboratory Services Division
<br />8100 Lowry Boulevard, Denver, CO 80230-6928
<br />US Mail: PO Box 17123, Denver, CO 80217
<br />(303) 692-3090 fax (303) 344-9989
<br />Colarada ?axt
<br />Of Public. Health
<br />and Emimnmcut
<br />REQUEST FOR ANALYTICAL SERVICES
<br />Collection No: ? [1[1[]? ? ? O
<br />CustomerlD : 00009830 ??
<br />??
<br />?? Ell c 110 ? a.m
<br />Collected: Time
<br />Name : Department of Natural Resources _
<br />_
<br />[1 P.M
<br />Address : 1313 Sherman Street Room 215 month day year hour min
<br /> Collected by: Water Type:
<br />City/St/Zip : Denver CO 80203
<br />Phone : 303-866-3567 Purpose: E] Routine ? Special Purpose Repeat
<br />Email
<br />Contact : Berhan Keffelow ? Compliance ? Personal Information
<br />Fax:
<br />SAMPLE Chlorine residual: n ,ln mg/L Water Temperature Do- C
<br />'WS ID: Coo ? ? ? ? ? ? ? ? Fluoride [] . 0[][] mg/L
<br />System Name:
<br />Temperature at Receipt:
<br />,ddress: Comments:
<br />City County State Lip
<br />
<br />)escription:
<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 ?EDB/DBCP ? BOD ?CBOD ?DO ?VOCs Screen
<br />(Coliform Bacteria, Nitrate/Nitrite) ?Chlorinated Pesticides 0Chemical Oxygen Demand (COD) ?SVOCS/Pesticide
<br />[]Expanded Annual Colorado []PCBs (Subcontracted) 0Chloride Screen
<br />Package (Coliform Bacteria, ?Chlorinated Herbicides 0Chlorine ?BTEX
<br />Nitrate/ Nitrite, pH, TDS) ?Volatile Organic Compounds (VOCs) ?Chromium, hexavalent (Cr's) Radiochemistry
<br />[]General Colorado Package ?Semivolatile Organic Compounds (SVOCs) ?Corrosivity (Langlier) ?Gross Alpha/Beta
<br />(Arsenic, Coliform Bacteria, Hardness, ?Carbamate Pesticides Cyanide ? Direct ? Distilled ?Radium 226
<br />Copper, Fluoride, Iron, Lead, ?Diquat (Subcontracted) ? WAD ?Radium 228
<br />Nitrate/Nitrite, Uranium) ?Endothall 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 ?Ni-63
<br />Conductivity, Copper, Corrosivity, Ni, Se, Na Tl) + 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 Tl) + 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 []Strontium 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 ?Haloacetic Acids (HAA5s) []Phenol Metals (list):
<br />?Drillin
<br />Baseline Packa
<br />e (Volatile ?Alkalinity Phosphorus
<br />g
<br />g
<br />Or
<br />anic Com
<br />ound Screen
<br />H
<br />Total ?Bromate []Bromide ?Bromite ?Phosphate, Ortho
<br />g
<br />p
<br />, p
<br />,
<br />Dissolved Solids, Chloride, Fluoride, []Chlorate []Chlorite ?Phosphate, Total []Bacteria in Food
<br />Alkalinity, Sulfate, Nitrate/Nitrite, Organic Carbon []Total ? Dissolved ?Sodium Adsorption Ratio Suspect:_
<br />Arsenic, Barium, Calcium, Chromium, ?UV @ 254 Solids []Dissolved []Settleable Suspect:_
<br />Iron
<br />Magnesium
<br />Selenium
<br />Sodium Total Coliform Rule Microbiolo /Bacteria []Suspended []Total ?Volatile Miscellaneous
<br />,
<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) ? Sulfate 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 ?0ther 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/lr/lrhom.htm Report #250Req
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