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r. Laboratory and Radiation Services Division <br />8100 Lowry Boulevard, Denver CO 8( System ID ENV-2009010241 <br />US Mail: PO Box 17123, Denver CO I Collection Date 9/14/2009 9:30:OOAM <br />ca?e?eon (303) 692-3090 fax (303) 344-9989 Control Number 47 <br />W <br />REQUEST FOR ANALYTICAL SEF <br /> CUSTOMER SAMPLE IrA FORIMATION <br /> <br />.? Customerio <br /> <br /> <br />Q <br />" <br />) Collected: / <br />- Time: UNN u nr <br /> <br /> <br />M. <br />? P <br /> Name j <br />. <br />?CC. <br />L1 month day year <br />. <br />hour min <br /> Xt <br />? <br />Address: <br />-L?W eo <br /> _. <br />_ Collected by: Matr uc <br /> ?p <br />Cd <br />'zii <br /> y <br />p. ? Surface W <br />te <br /> <br />Contact Phone (j63, a <br />r <br />? Ground Water <br />? Treated <br />t <br /> Wa <br />er <br /> SAMPLE SITE C • <br /> PWS ID: P <br /> <br />) \ urpose : ? Routine ? Special Pu rpose ? Repeat <br /> Sample Location: U <br />t0 <br /> tion: <br />D <br />«; Chlorine residual: [1.111 MGIL Temp.. Water: F <br />. es <br />p <br />x . <br />t <br />C <br /> Address: ommen <br />s: <br /> Ckr St $?. <br />? <br />TEST ORDER (Che ck appropriate box) <br />CHEMISTRY- INORGANIC CHEMISTRY- ORGANIC RADIOCHEMISTRY <br />? Alkalindy, Phenolphthalein 0 Molybdenum ? Carbamates ? Alpha/Bete, Gross <br />? Alkalinity, Total ? Nickel ? VOC ? Americium <br />-O .Aluminum- -?- Ntrogen, Ammonia Dist. _ ^-? THM - ?? Carbon-14 <br />O Antimony ? N'drogen, IQeldahl ? BTEX O Gamma Screen <br />? Arsenic O Nitrogen, Total' ? DIQUAT . Gamma Spectrometry, <br />? <br />D Barium O Nitrate/Nitrite O SOC <br />Nuclide Specific <br />? Beryllium ? N&he ? SVOC ? Leak Test <br />? BOO ? pH ? Pesticides ? Plutonium <br />? Boron O Phosphate, Ortho ? Gyphosate ?, Radium 226 <br />? Cadmium ? Phosphate, Total ? Herbicides ? Radium 228 <br />? Calcium ? Potassium ? EDBIDBCP ? .Radon <br />? Chloride <br />? Selenium ? PCB ? Thorium <br />? Chlorine, total residual ? Silicon (silicates) o ? TOC ? Tritium <br />? Chromium ? DRO ? Other. <br />? Conductivity O Silver ? HEM (08 Grease) ? Other. <br />O Copper ? Sodium ? Other <br />? Comosivity (record t ? Solids, Dissol"d ? Other: <br />MICROBIOLOGY <br />Cyanide, Dist. W Solids, Suspended <br />oride ? Solids, Total ? Total Coliforms, PA <br />? Hardness, total O Sulfate phase 1,2,5 -ANALYSES O Total Cordomns, MTF <br />O iron ? Thallium ? Heterotrophic Plate Count <br />I:1 Lead ? Uranium ? Organic (SOC / VOC) ? Pseudomonas MPN <br />? Magnesium Cl Zinc ? Inorganic ? E. Coh., MPN <br />? Manganese ? Other. •? Other <br />C Mercury ? Other: l <br />S O ? Other. <br /> ir Lr) <br />i I <br /> <br />Z. <br />C? <br />LARS Internet Address: http:/hvww.cdphe.state.co.usAr/lrhom.htm <br />Report 0280Req. Rev 12MIN co LTi