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Laboratory Services Division
<br />Gig 8100 Lowry Boulevard, D
<br />} US Mail: PO Box 17123,1
<br />(303)692 -3090 fax (31
<br />Svstem ID ENV-2009011198
<br />tg'(U
<br />loradoDcpaztmmt Collection Date
<br />oFPublicAmirh
<br />and Etv Control Number 1
<br />irowumt
<br />REQUEST FOR ANALYTIC, ._
<br />-100000E0
<br />erlD :
<br />a
<br />00009830
<br />Collected: []E ? a.m
<br />Time o
<br />me :
<br />ame of Natural Resources
<br />Department
<br />month day year hour ? p•m
<br />min
<br />ddress : 1313 Sherman Street Room 215
<br /> Collected by : Water Type:
<br />:ity/St/Zip : Denver CO 80203
<br />3567
<br />303
<br />866
<br />Purpose:
<br />E] Routine ? Special Purpose
<br />Repeat
<br />-
<br />-
<br />phone :
<br />:mail:
<br />:ontact : Berhan Keffelow
<br />? Compliance Personal Information
<br />'ax:
<br />SAMPLE SITE Chlorine residual: 0-op mg/L Water Temperature
<br />C
<br />'WS ID;? . COQ ? P ? . ? Fluoride [1-11011 mg/L
<br />?-
<br />l
<br />ystem Name:
<br />' Temperatu re at Receipt: 1 / e
<br />ddress: Comments:
<br />Count
<br />cit y State IP
<br />y
<br />, C
<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 []Chlorine
<br />6 ?BTEX
<br />Nitrate/ Nitrite, pH, TDS) - ?Vblatire Organic Compounds (VOEs-) - )v
<br />-[]Chromium--hexavalent-(Cr+ -Radiochemistry _
<br />[]General Colorado Package ?Semivolatile Organic Compounds (SVOCS) vity (Langlie) []Gross Alpha/Beta
<br />(Arsenic, Coliform Bacteria, Hardness, DCarbamate Pesticides P []Radium 226
<br />[]Radium 228
<br />Copper, Fluoride, Iron, Lead, ?Diquat (Subcontracted) AD []Uranium
<br />Nitrate/Nitrite, Uranium) ?Endothall
<br />lypho []Hardness ?C-14
<br />
<br />6Lff P.
<br />[]Deluxe Colorado Package
<br />S
<br />Arsenic, Ca mium, IC
<br />(Alkalinity
<br />jn
<br />an Ch f Is Rule
<br />
<br />[]Mercury
<br />
<br />[]Radon
<br />,
<br />Chi ide
<br />Coliform Bacteria Sb, As, Ba, Be, Cd, Cr, Hg,
<br />rims M t Individual Metals []Aluminum ?Ni-63
<br />,
<br />Copper
<br />orrt
<br />Conductivity l
<br />i, Se, Narn ) uoride []Antimony []Arsenic []Barium []Gamma Spectrometr
<br />,
<br />,
<br />III r
<br />Lead
<br />Fluoride
<br />Hardness []Primary Met s (Sb, As, Ba, Be, Cd, Cr, Hg , []Beryllium []Cadmium []Calcium Specific Isotopes (list):
<br />,
<br />,
<br />,
<br />,
<br />Magnesium, Manganese, Ni, Se, Na Ti) + Fluoride + Cyanide []Chromium []Cobalt []Copper
<br />Nitrate/Nitrite, pH, Sodium, Sodium Nitrogen, []Nitrate ? Nitrite
<br />Lead and Copper Rule []Iron []Lead []Magnesium
<br />[]Manganese ? Molybdenum
<br />Food Testing
<br />Adsorption Ratio, Sulfate, Total
<br />Zinc)
<br />Uranium
<br />Dissolved Solids []Lead and Copper []Nickel []Potassium []Selenium []Equilibrium pH
<br />,
<br />,
<br />[]Mining Baseline Package (pH, Radionuclides Rule []Silver []Sodium []Strontium []Starch
<br />Arsenic,
<br />Aluminum
<br />Nitrate/Nitrite []Gross Alpha/Beta []Sulfur []Thallium []Tin []Fat
<br />,
<br />,
<br />Copper
<br />Iron
<br />Lead
<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 />h []pH []Mercury
<br />[]Mining Baseline Package without s)
<br />anes (
<br />?TotalTrihalomet []Ph
<br />l Metals (list):
<br />Gross Alpha/Beta ?Haloacetic Acids (HAA5s) eno
<br /> linit
<br />?Alk Phosphorus -
<br />[]Drilling Baseline Package (Volatile y
<br />a
<br />mate []Bromide []Bromie
<br />?Br Ortho
<br />[]Phosphate -
<br />Organic Compound Screen, pH, Total o
<br />[]Chlorate []Chlorite ,
<br />Total
<br />[]Phosphate []Bacteria in Food
<br />Dissolved Solids, Chloride, Fluoride,
<br />Nitrate/Nitrite
<br />Alkalinity
<br />Sulfate Organic Carbon []Total ? Dissolved ,
<br />[]Sodium Adsorption Ratio Suspect:- _
<br />,
<br />,
<br />,
<br />Arsenic, Barium, Calcium, Chromium, ?UV @ 254 Solids []Dissolved []Settleable Suspect:_
<br />llaneous
<br />Mi
<br />Selenium
<br />Sodium
<br />nesium
<br />Ma
<br />Iron Total oliform Rule Microbiolo /Bacteria []Suspended []Total []Volatile sce
<br />,
<br />,
<br />,
<br />g
<br />, / E
<br />li
<br />/Ab Conductance
<br />ifi
<br />[]S []Soils/Filters - XRF
<br />and Uranium)
<br />Sulfur sent, w
<br />. co
<br />)
<br />[]Total Coliform (Present pec
<br />c
<br />,
<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 />[]Unknown Substance
<br />Barium, Beryllium, Cadmium, Calcium, ?Heterotrophic Plate Count []Other Inorganic: Identification (FTIR)
<br /> []Other Microbiology:
<br />Chromium, Copper, Iron, Lead, --
<br />Magnesium, Manganese, Molybdenum, --
<br />l
<br />i
<br />m
<br />Silver
<br />i
<br />S
<br />Ni
<br />k
<br />l
<br />P
<br />t - -
<br />,
<br />,
<br />um,
<br />e
<br />en
<br />u
<br />e
<br />,
<br />o
<br />ass
<br />c
<br />Sodium, Uranium, Zinc
<br />CHAIN OF CUSTODY:
<br />RELINQUISHED BY: DATE/TIME: RECEIVED DATE/TIME:
<br />RELINQUISHED BY: DATE/TIME: RECEIVED BY: D TNE/T t1
<br />/
<br />RELINQUISHED BY: DATE/TIME: RECEIVED BY: DATE/TI E:
<br />LSD Interent Address: http://www.cdphe.state.co.us/Ir/lrhom.htm Report #250Req
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