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Laboratory Services Division
<br />8100 Lowry Boulevard, Denver, CO 802
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<br />US Mail: PO Box 17123, Denver, CO 8C
<br />303) 692-3090 fax (303) 344-9989 System ID ENV-2009012307
<br />col Mt Collection Date 10/26/2009 9:15:OOAM
<br />th Control Number '22
<br />Ertiuironmaati
<br />REQUEST FOR ANALYTICAL SERVn co II
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<br />CUSTOMER _
<br />INFORMATION
<br />CustomerID:
<br />00009830
<br />Name:
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<br />Address : 1313 Sherman Street Room 215 month day year hour min
<br />City/St/Zip : Denver CO 80203 Collected by : Water Type:
<br />Phone : 303-866-3567 Purpose: Routine ? Special Purpose F? Repeat
<br />Email:
<br />Contact : Berhan Keffelow Compliance [] Personal Information
<br />Fax:
<br />SAMPLE SITE Chlorine res idual: mg/L Water Temperature
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<br />PWS ID: COO ?
<br />? ? n n ? ? ? Fluoride mg/L
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<br />System Name:
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<br />Address: Comments:
<br />City o n State Zip
<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 ?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 ?BTEX
<br />Nitrate/ Nitrite, pH, TDS) ?Volatile Organic Compounds (VOCSL
<br />-_ ?Chromium, hexayaler?LL?r h emistr_v_
<br />BA ft c
<br />06eneraf Colorado Package .
<br />?Semivolatile Organic Compounds (SVOCs) - _
<br />O sivlty (Langlier) -
<br />?Gross Alpha/Beta
<br />(Arsenic, Coliform Bacteria, Hardness, ?Carbamate Pesticides yanrde ? Direct [] Distilled
<br />A []Radium 226
<br />Copper, Fluoride, Iron, Lead, ?Diquat (Subcontracted) ?Radium 228
<br />Nitrate/ Nitrite, Uranium) ndothgJ6 []Fluoride ?Uranium
<br />[]Deluxe Colorado Package
<br />(Alkalinity, Arsenic, Cadmium, IciW, Lj
<br />In i emic u []Hardness
<br />[]Mercury OC-14
<br />[]Radon
<br />Coliform Bacteria
<br />Chlorid ri r
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<br />Sb
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<br />B
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<br />e, Cd, Cr, Hg, Individual Metals []Aluminum ?Ni-63
<br />Conductivity, Copper, Corrosivity, Ni, Se, Na TI) + Fluoride []Antimony []Arsenic []Barium []Gamma Spectrometr
<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 />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 []Starch
<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 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 OBromate []Bromide OBromie []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 />Sulfur, and Uranium) []Total Coliform (Present/Absent, w/ E. coli) []Specific 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, Manganese
<br />Molybdenum
<br />,
<br />,
<br />Nickel, Potassium, Selenium
<br />Silver
<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: AT /T, III E:
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<br />RELINQUISHED BY:
<br />DATE/TIME:
<br />RECEIVED BY: ?
<br />O L1p
<br />DATE/TIME:
<br />LSD Interent Address: http://www.cdphe.state.co.us/lr/lrhom.htm Report #250Req is
<br />LT
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