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Laboratory Services Division <br />8100 Lowry Boulevard, Denver, CO 80210-13828 <br />US Mail: PO Box 17123, Denver, CO <br />(303) 692-3090 fax (303) 344-998! <br />Svstem ID ENV-2009012308 <br />40 Collection Date 10/26/2009 10:55:OOAM <br />1U11 ? <br />rrment Control Number 23 ? ? ? <br />REQUEST FOR ANALYTICAL SE <br />CUSTOMER <br />CustomerlD : 00009830 o a.m <br />Name : Department of Natural Resources Collected: Time o ? p.m <br />Address : 1313 Sherman Street Room 215 month day year hour min <br />Collected by: Water Type: <br />City/SUZip : Denver CO 80203 <br />Phone : 303-866-3567 Purpose: ? Routine ? Special Purpose Repeat <br />Email: <br />Contact : Berhan Keffelow ? Compliance ? Personal Information <br />Fax: <br />SAM, PLE SITE Chlorine residual: mg/L Water Temperature oo DC <br />PWS ID: coo [I [I [11111 Fluoride , mg/L <br />System Name: C <br />Temperature at Receipt: <br />Address: , r. Comments: <br />City oun State Lip <br />Description: <br />Location Source <br />[]Real Estate/HUD (Coliform Bacteria, <br />Lead, Nitrate and Nitrite) <br />[]Annual Colorado Package <br />(Coliform Bacteria, Nitrate/Nitrite) <br />[]Expanded Annual Colorado <br />Package (Coliform Bacteria, <br />Nitrate/Nitrite, pH, TDS) <br />-[]"GenereTColorudo Pac ag- e <br />(Arsenic, Coliform Bacteria, Hardness, <br />Copper, Fluoride, Iron, Lead, <br />Nitrate/ Nitrite, Uranium) <br />[]Deluxe Colorado Package <br />(Alkalinity, Arsenic, Cadmiu , Cal <br />Coliform Bacteria, Chloride, <br />Conductivity, Copper, Corro it y* <br />Fluoride, Hardness, Iron, Lea <br />Magnesium, Manganese, <br />Nitrate/Nitrite, pH, Sodium, Sodium <br />Adsorption Ratio, Sulfate, Total <br />Dissolved Solids, Uranium, Zinc) <br />[]Mining Baseline Package (pH, <br />Nitrate/ Nitrite, Aluminum, Arsenic, <br />Cadmiun, Copper, Iron, Lead, <br />Magnesium, Manganese, Potassium, <br />Selenium, Sodium, Sulfur, Uranium, <br />Sulfate, Gross Alpha/Beta) <br />[]Mining Baseline Package without <br />Gross Alpha/Beta <br />[]Drilling Baseline Package (Volatile <br />Organic Compound Screen, pH, Total <br />Dissolved Solids, Chloride, Fluoride, <br />Alkalinity, Sulfate, Nitrate/Nitrite, <br />Arsenic, Barium, Calcium, Chromium, <br />Iron, Magnesium, Selenium, Sodium, <br />Sulfur, and Uranium) <br />[]Drilling Baseline Package without <br />VOC screen. <br />[]Metals Scan: (Aluminum, Arsenic, <br />Barium, Beryllium, Cadmium, Calcium, <br />Chromium, Copper, Iron, Lead, <br />Magnesium, Manganese, Molybdenum, <br />Nickel, Potassium, Selenium, Silver, <br />Sodium, Uranium, Zinc) <br />CHAIN OF CUSTODY: <br />RELINQUISHED BY: <br />COMPLIANCE DRINKING WATER TESTS <br />Organic Chemicals Rule <br />?EDB/DBCP <br />[]Chlorinated Pesticides <br />[]PCBs (Subcontracted) <br />[]Chlorinated Herbicides <br />[]Volatile Organic Compounds (VOCs) <br />?Semivolatile"OCgamc Compounds (SVOU <br />?Carbamate Pesticides <br />?Diquat (Sub?Dntracted) <br />[]Endo_Lall / . i <br />EPM1My Metals (Sb, s, Ba, Be, Cd, Cr, Hg, <br />Ni, Se, Na TI) + Fluori e <br />[]Primary Metals (Sb, As, Ba, Be, Cd, Cr, Hg, <br />Ni, Se, Na TI) + Fluoride + Cyanide <br />Nitrogen, []Nitrate ? Nitrite <br />Lead and Copper Rule <br />[]Lead and Copper <br />Radionuclides Rule <br />[]Gross Alpha/Beta <br />[]Radium 226 <br />[]Radium 228 <br />[]Uranium <br />[]Total Trihalomethanes (TTHMs) <br />?Haloacetic Acids (HAA5s) <br />[]Alkalinity <br />?Bromate []Bromide ?Bromie <br />[]Chlorate []Chlorite <br />Organic Carbon []Total ? Dissolved <br />?UV @ 254 <br />[]Total Coliform (Present/Absent, w/ E. coli) <br />?E. coli (Enumerated, w/ Total Coliform) <br />[]Total Coliform (Multiple Tube enumeration) <br />?Coliform, Fecal (Multiple Tube enumeration) <br />?Heterotrophic Plate Count <br />[]Other Microbiology: <br />Inorganic Parameters <br />[]Alkalinity <br />? BOD ?CBOD ?DO <br />[]Chemical Oxygen Demand (COD) <br />[]Chloride <br />[]Chlorine <br />[]Chromium, hexavalent (Cr+6) <br />Cyanide ? Direct ? Distilled <br />%WAD <br />? Fluoride <br />? Hardness <br />? Mercury <br />Individual Metals []Aluminum <br />[]Antimony []Arsenic []Barium <br />[]Beryllium []Cadmium []Calcium <br />[]Chromium []Cobalt []Copper <br />[]Iron []Lead []Magnesium <br />[]Manganese []Molybdenum <br />[]Nickel []Potassium []Selenium <br />[]Silver []Sodium []Strontium <br />[]Sulfur []Thallium []Tin <br />[]Tungsten []Uranium []Zinc <br />Nitrogen, []Ammonia <br />? Nitrate/Nitrite ? Total Kjeldahl <br />[]Nitrate [] Nitrite <br />? pH <br />? Phenol <br />Phosphorus <br />[]Phosphate, Ortho <br />[]Phosphate, Total <br />[]Sodium Adsorption Ratio <br />Solids []Dissolved []Settleable <br />[]Suspended []Total []Volatile <br />[]Specific Conductance <br />? S u Ifa to <br />? Sulfide <br />? Turbid ity <br />[]Other Inorganic: <br />DATE/TIME: I RECEIVED BY: <br />Organic Parameters <br />[]Oil and Grease <br />?VOCs Screen <br />?SVOCS/Pesticide <br />Screen <br />?BTEX <br />Radiochemistry <br />[]Radium 226 <br />[]Radium 228 <br />[]Uranium <br />?C-14 <br />[]Radon <br />? N i-63 <br />[]Gamma Spectromet <br />Specific Isotopes (list): <br />Foot/ Testing <br />[]Equilibrium pH <br />[]Starch <br />[]Fat <br />[]Water Activity <br />Preservatives (list): <br />u Ivl ercury <br />Metals (list): <br />[]Bacteria in Food <br />Suspect:` <br />Suspect:- <br />Miscellaneous <br />[]Soils/Filters - XRF <br />metals (list): <br />[]Unknown Substance <br />Identification (FTIR) <br />TE/TIME: <br />I RELINQUISHED BY: I DATE/TIME: I RECEIVED BY: 1-STATE/TIME: 1 <br />LSD Interent Address: http://www.cdphe.state.co.us/lr/lrhom.htin Report #250Req <br />1 <br />tr!