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r Laboratory Services Division
<br /><?; 8100 Lowry Boulevard, Denver, CO 80230-6928
<br />f?1 US Mail: PO Box 17123, Denver, CO 80217
<br />(303) 692-3090 fax (303) 344-9989
<br />Colorado Dgartmew
<br />of Pubtic&--dth
<br />and E"mummt
<br />REQUEST FOR ANALYTICAL SERVICES
<br />CustomerlD : 00009830
<br />Name : Department of Natural Resources
<br />Address : 1313 Sherman Street Room 215
<br />City/St/Zip : Denver CO 80203
<br />Phone : 303-866-3567
<br />Email:
<br />Contact : Berhan Keffelow
<br />Fax:
<br />Pws?? ??o F1 11 n11 o11 -uuo
<br />System Name:
<br />Address:
<br />S( Ica
<br />Ip
<br />city
<br />' , l oun State
<br />Description: U -m w 2? 5,
<br />Location Somte
<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 />[]General Colorado Package
<br />(Arsenic, Coliform Bacteria, Hardness,
<br />Copper, Fluoride, Iron, Lead,
<br />Nitrate/ Nitrite, Uranium)
<br />[]Deluxe Colorado Package
<br />(Alkalinity, Arsenic, Cadmium, Calcium,
<br />Coliform Bacteria, Chloride,
<br />Conductivity, Copper, Corrosivity,
<br />Fluoride, Hardness, Iron, Lead,
<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 />?Drllling 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 />?Drllling 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 />System ID ENV-2010005510
<br />Collection Date 5/13/2010 9:10:00AM
<br />Control Number 66
<br />u L---J l-I IJ I?l l-1, 10
<br />Collected: 10-ffil _ ©® Time [IN
<br />month day year hourrrll??
<br />-ollected by: Water Type:
<br />Purpose: [] Routine E] Special Purpose
<br />? Compliance ? Personal Information
<br />Chlorine residual: 0.00 mg/L Water Temperature 00 0C
<br />Fluoride m9/L
<br />Temperature at Receipt: Yc
<br />Comments:
<br />:W g a.m
<br />min p.m
<br />Repeat
<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 />-?Serntvolatite Organic Compounds (SVOCsJ
<br />?Carbamate Pesticides
<br />?Diquat (Subcontracted)
<br />?Endothall
<br />?Glyphosate
<br />Inorganic Chemicals Rule
<br />?Primary Metals (Sb, As, Ba, Be, Cd, Cr, Hg,
<br />Ni, Se, Na TI) + Fluoride
<br />?Primary Metals (Sb, As, Ba, Be, Cd, Cr, Hg,
<br />Ni, Se, Na Tl) + 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 />?VOCs Screen
<br />?SVOCS/Pesticide
<br />Screen
<br />?BTEX
<br />Radiochemistry
<br />-[]Gross Alpha/Beta
<br />?Radium 226
<br />?Radium 228
<br />?Uranium
<br />?C-14
<br />[]Radon
<br />? N i-63
<br />[]Gamma Spectrometl
<br />Specific Isotopes (list):
<br />Food Testing
<br />[]Equilibrium pH
<br />[]Starch
<br />[]Fat
<br />[]Water Activity
<br />Preservatives (list):
<br />[]Mercury
<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 />?A BOD,,,RC80D MDp°,
<br />f] roi&-0°4? 6`n' De MLA d (COD)
<br />[]Chloride
<br />[]Chlorine
<br />?Chromium, hexavalent (Cr•e)
<br />-[]-Eorrosivity-(Langlier--)-_ - _
<br />Cyanide ? Direct ? Distilled
<br />? WAD
<br />? Fluoride
<br />? Hardness
<br />? Mercu ry
<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 />? Sulfate
<br />[]Sulfide
<br />? Turbidity
<br />? Other Inorganic:
<br />RELINQUISHED BY: DATE/TIME: RECEIVED BY: DATE/TIME:
<br />RELINQUISHED BY: DATE/TIME: RECEIVED BY: DATE/TIME:
<br />RELINQUISHED BY: DATE/TIME: RECEIVED BY: DATErrIME:
<br />LSD Interent Address: http://www.cdphe.state.co.us/lr/frhom.htm Report 4250Req
<br />0.? W M410 Ta`'
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