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brads 17cpae#nmt
<br />of PubltcHeAth
<br />and EwAronment
<br />Laboratory Services Division
<br />8100 Lowry Boulevard, Denver, C-
<br />US Mail: PO Box 17123, Denver, ,
<br />(303) 692-3090 fax (303) 344-9 System ID ENV-2009012306
<br />Collection-Date 10/26/2009 10:50:OOAM
<br />Control Number 21
<br />REQUEST FOR ANALYTICAL SI u u LJ 111111110
<br />CUSTOMER SPECIMEN INFORMATION
<br />(a
<br />erlu : Collected: 16n Time ?d
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<br />6 o W 1 a m
<br />me :
<br />Name D
<br />Department of Natural Re sources _
<br />Ll?JbJ
<br />1%? p.
<br />Address : 1313 Sherman Street Room 215 month day year hour i n
<br />m
<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
<br />i Chlorine res idual: ,?? mg/L Water Temperature 0C
<br />0
<br />PWS ID: coo ? ? ? Fluoride [].[I[][] mg/L
<br />System Name: Temperature at Receipt: / k C
<br />Address:
<br />`
<br />Comments:
<br />City oun State
<br />Ip
<br />- -
<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 ?EDB/DBCP ? BOD ?CBOD ?DO OVOCs 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 (Cris) Radiochemistry
<br />[]General Co or-1 ado Pac agd - ?Semivotafile Orgamc oC- mpounds (SVOCs) - -??ity (anglier) ro?G ssAlpha/Beta -
<br />(Arsenic, Coliform Bacteria, Hardness, ?Carbamate Pesticides ? Direct ? Distilled []Radium 226
<br />Copper, Fluoride, Iron, Lead, ?Diquat (Subcontracted) ?Radium 228
<br />N itrate/Nitrite, Uranium) ?Endothall 0Fluoride ?Uranium
<br />[]Deluxe Colorado Package ?Glyphosate ? Hardness ?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 TI) + F ride []Antimony []Arsenic []Barium []Gamma Spectrometr
<br />Fluoride, Hardness, Iron, Lead, ? a A Cd, Cr, Hg,
<br />" []Beryllium []Cadmium []Calcium Specific Isotopes (list):
<br />Magnesium, Manganese, nde
<br />+ y Vide
<br />Ni, + uo
<br />?Chromium []Cobalt []Copper
<br />_
<br />Nitrate/Nitrite, pH, Sodium, Sodium n, ? rate ? Nitrite []Iron ?Lead []Magnesium _
<br />Adsorption Ratio, Sulfate, Total Lad 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 []Water Activity
<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 B roducts []Nitrate ? Nitrite
<br />[]Mining Baseline Package without []Total Trihalomethanes (TTHMs) []pH ?Mercury
<br />Gross Alpha/Beta ?Haloacetic Acids (HAA5s) ? Phenol Metals (list):
<br />[]Drilling Baseline Package (Volatile []Alkalinity Phosphorus _
<br />Organic Compound Screen, pH, Total ?Bromate []Bromide ?Bromie []Phosphate, Ortho
<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, Magnesium, Selenium, Sodium Total Coliform Rule Microbiolo /Bacteria []Suspended []Total ?Volatile Miscellaneous
<br />,
<br />Sulfur, and Uranium) []Total Coliform (Present/Absent, w/ E. Coll) 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, Copper, Iron, Lead, []Other Microbiology: Identification (FTIR)
<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 />
<br />MOONS
<br />CHAIN OF CUSTODY:
<br />RELINQUISHED BY: DATE/TIME: RE CEIVED BY. DA(D?/TIME:
<br />RELINQUISHED BY: DATE/TIME: RECEIVED BY: DA?'/TrIMF./ '
<br />RELINQUISHED BY: DATE/TIME: RECEIVED BY: DATEITIME:
<br />3
<br />LSD Interent Address: http://www.cdphe.state.co.us/lr/lrhom.htm Report 4250Req Is
<br />CT
<br />LC
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