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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 />'A tM Tli s
<br />Colorado Dcpar Awt
<br />of Public }fcalib
<br />and E.mimamcnt
<br />REQUEST FOR ANALYTICAL SERVICES
<br />Collection No: ? [11111111111
<br />:ustomerlD : 00009830
<br />Collected: ?? E[] o ?D ? a.m
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<br />Time o
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<br />ame :
<br />epartmen
<br />o month day year hour min
<br />,ddress : 1313 Sherman Street Room 215
<br /> Collected by : Water Type:
<br />:ity/St/Zip : Denver CO 80203
<br />303-866-3567
<br />Purpose:
<br />[] Routine Special Purpose
<br />? Repeat
<br />'hone :
<br />:mail:
<br />;ontact :
<br />E] Compliance Personal Information
<br />Berhan Keffelow
<br />ax:
<br />SAMPLE Chlorine res idual: mg/L Water Temperature Q
<br />? C
<br />WS ID: coo ? ? ? ? ? - F Fluoride [1 .000 mg/L
<br />ystem Name: Temperatu re at Receipt:
<br />,ddress: Comments:
<br />City Count y State Lip
<br />
<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 []Chemical Oxygen Demand (COD) ?SVOCS/Pesticide
<br />[]Expanded Annual Colorado []PCBs (Subcontracted) []Chloride Screen
<br />Package (Coliform Bacteria, ?Chlorinated Herbicides 0Chlorine
<br />{6 ?BTEX
<br />Nitrate/Nitrite, pH, TDS) ?Volatile Organic Compounds (VOCs) )
<br />?Chromium, hexavalent (Cr Radiochemistry
<br />[]General Colorado Package ?Semivolatile Organic Compounds (SVOCs) ?Corrosivity (Langlier) ?GrossAlpha/Beta
<br />Coliform Bacteria, Hardness,
<br />(Arsenic ?Carbamate Pesticides Cyanide ? Direct El Distilled ?Radium 226
<br />,
<br />Fluoride, Iron, Lead,
<br />Copper ?Diquat (Subcontracted) ? WAD ?Radium 228
<br />,
<br />Uranium)
<br />Nitrate/Nitrite ?Endothall 0Fluoride []Uranium
<br />,
<br />[]Deluxe Colorado Package ?Glyphosate 0Hardness ?C-14
<br />(Alkalinity, Arsenic, Cadmium, Calcium, Inorganic Chemicals Rule ?Mercury []Radon
<br />Chloride
<br />Coliform Bacteria ?Primary Metals (Sb, As, Ba, Be, Cd, Cr, Hg, Individual Metals []Aluminum ?Ni-63
<br />,
<br />,
<br />Copper, Corrosivity,
<br />Conductivity Ni, Se, Na TI) + Fluoride []Antimony []Arsenic []Barium []Gamma Spectrometr
<br />,
<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 />Sodium, Sodium
<br />pH
<br />Nitrate/ Nitrite Nitrogen, []Nitrate ? Nitrite []Iron []Lead []Magnesium
<br />,
<br />,
<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 />Arsenic,
<br />Aluminum
<br />Nitrate/ Nitrite []Gross Alpha/Beta []Sulfur []Thallium []Tin []Fat
<br />,
<br />,
<br />Iron
<br />Lead
<br />Copper
<br />Cadmiun ?Radium 226 []Tungsten ?Uranium []Zinc ?WaterActivity
<br />,
<br />,
<br />,
<br />,
<br />Magnesium, Manganese, Potassium, ?Radium 228 Nitrogen, []Ammonia Preservatives (list):
<br />Selenium, Sodium, Sulfur, Uranium, ?Uranium ? Nitrate/Nitrite ? Total Kjeldahl - -
<br />Gross Alpha/Beta)
<br />Sulfate Disinfection Byproducts []Nitrate ? Nitrite -
<br />, TTHM
<br />th
<br />T
<br />ih
<br />l ?pH ?Mercury
<br />?Mining Baseline Package without anes (
<br />s)
<br />r
<br />a
<br />ome
<br />?Total l
<br />? Ph Metals (list):
<br />Gross Alpha/Beta ?Haloacetic Acids (HAA5s) eno
<br /> linit
<br />?Alk Phosphorus -
<br />[]Drilling Baseline Package (Volatile y
<br />a -
<br /> ?Bromate []Bromide ?Bromie []Phosphate
<br />Ortho
<br />Organic Compound Screen, pH, Total []Chlorate []Chlorite ,
<br />Total
<br />[]Phosphate []Bacteria in Food
<br />Dissolved Solids, Chloride, Fluoride,
<br />Nitrate/Nitrite
<br />Alkalinity
<br />Sulfate Organic Carbon []Total ? Dissolve d ,
<br />[]Sodium Adsorption Ratio Suspect:_
<br />,
<br />,
<br />,
<br />Arsenic, Barium, Calcium, Chromium, ?UV @ 254 Solids []Dissolved []Settleable Suspect:
<br />Mi
<br />cellaneous
<br />Sodium
<br />nesium
<br />Selenium
<br />Iron
<br />Ma Total Coliform Rule Micr bi to /Bac eria []Suspended []Total ?Volatile s
<br />,
<br />,
<br />,
<br />,
<br />g
<br />and Uranium)
<br />Sulfur []Total Coliform (Present/Absent, w/ E. coli) []Specific Conductance []Soils/Filters - XRF
<br />,
<br />[]Drilling Baseline Package without ?E. coli (Enumerated, w/ Total Coliform) []Sulfate metals (list):
<br />VOC screen. []Total Coliform (Multiple Tube enumeration) 0Sulfide - -
<br />?Metals Scan: (Aluminum, Arsenic, ?Coliform, Fecal (Multiple Tube enumeration ) []Turbidity
<br />[]Unknown Substance
<br />Barium, Beryllium, Cadmium, Calcium, ?Heterotrophic Plate Count []Other Inorganic: ntification (FTIR)
<br />Id
<br /> []Other Microbiology: e
<br />Chromium, Copper, Iron, Lead,
<br />d --
<br />-
<br />enum,
<br />Magnesium, Manganese, Molyb
<br />il -
<br />-
<br />ver,
<br />Nickel, Potassium, Selenium, S -
<br />Sodium, Uranium, Zinc
<br />CHAIN OF CUSTODY:
<br />RELiNQUISHED BY: DATE/TIME: R ECEIVED BY: DATE/TIME:
<br />UISHED BY: DATE/TIME: RECEIVED BY DATE/TIME:
<br />UISHED BY:
<br />F 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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