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<br />Colorado D of
<br />of Public ealth
<br />and Emironment
<br />Laboratory Services Division
<br />8100 Lowry Boulevard, Denver, CO 80230-6928 -
<br />US Mail: PO Box 17123, Denver, CO 80217 System ID
<br />(303) 692-3090 fax (303) 344-9989 Collection Date
<br />Control Number
<br />ENV-2010005508
<br />5/13/2010 10:30:00AM
<br />64 , I lip
<br />REQUEST FOR ANALYTICAL SERVICES
<br />
<br />• - --
<br /> INFORMATION
<br />Custom
<br />Name : erlD : Department of Natural Resources
<br />
<br />Name
<br />Collected:
<br />®? T? _ ?© Time
<br />VE
<br />a.m
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<br />Address : 1313 Sherman Street Room 215 month day year hour min p.m
<br />City/St/Zip : Denver CO 80203
<br />Collected by:
<br />Water Type:
<br />Phone : 303-866-3567 Purpose: Routine Special Pur
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<br />eat
<br />Email: p p
<br />Contact : Berhan Keffelow
<br />Fax: Compliance Ej Personal Information
<br />SAMPLE SITE Chlorine resi dual: mg/L Water Temperat ure
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<br />PWS ID: coo ? ? ? ? ? ? - ?
<br />P Fluoride .111111 mg/L
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<br />System Name:
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<br />- - Temperature at Receipt:
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<br />Address: r ?
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<br />1 z co Comments:
<br />County
<br />za}? a- zip
<br />City
<br />Description: M I N [S ?S C
<br />Location Source
<br />[]Real Estate/HUD (Coliform Bacteria,
<br />L
<br />d
<br />Nit
<br />t COMPLIANCE DRINKING WATER TESTS Inorganic Parameters Oraanic Parameters
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<br />,
<br />ra
<br />e 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 f ,?1 ??
<br />c
<br />al Oxygen Demand (COD)
<br />t ?SVOCS/Pesticide
<br />[]Expanded Annual Colorado []PCBs (Subcontracted) o
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<br />irL1
<br />Chde4 ?t•1 d
<br />l„2I
<br />-,k Screen
<br />Package (Coliform Bacteria, ?Chlorinated Herbicides -
<br />L
<br />[]Chlorine ?BTEX
<br />Nitrate/Nitrite, pH, TDS) ?Volatile Organic Compounds (VOCs) ?Chromium, hexavalent (Cr+6) Radiochemistry
<br />[]General Colorad6 Package - -[]Semivolatile-Organic Compounds-(SVOCs) ?-C-orrosiuity (Langlier)_ -EI.Gros_5Alpha/Beta
<br />(Arsenic, Coliform Bacteria, Hardness, ?Carbamate Pesticides Cyanide O Direct ? Distilled ?Radium 226
<br />Copper, Fluoride, Iron, Lead, ?Diquat (Subcontracted) ADG----- ?Radium 228
<br />Nitrate/Nitrite, Uranium) ?Endothall [Fluoride []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) + Fluoride []Antimony []Arsenic []Barium []Gamma Spectrometry
<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 []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 Byproducts ?Nitrate 0 Nitrite
<br />?Mining Baseline Package without []Total Trihalomethanes (TTHMs) ?pH ?Mercury
<br />Gross Alpha/Beta CHaloacetic Acids (HAA5s) []Phenol Metals (list):
<br />?Drilling Baseline Package (Volatile ?Alkalinity Phosphorus
<br />Organic Compound Screen, pH, Total ?Bromate []Bromide ?Bromite ?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 g _
<br />Barium, Beryllium, Cadmium, Calcium, ?Heterotrophic Plate Count []Other Inorganic: []Unknown Substance
<br />Chromium, Copper, Iron, Lead, []Other Microbiology: Identification
<br />(FTIR)
<br />Magnesium, Manganese
<br />Molybdenum
<br />,
<br />,
<br />Nickel
<br />Potassium
<br />Selenium
<br />Silver
<br />,
<br />,
<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: DATE/TIME:
<br />RELINQUISHED BY: DATE/TIME: RECEIVED BY: DATE/TIME:
<br />Q S ?I?COs?
<br />Interent Address: http://www.cdphe.state.co.us/lr/lrhom.htm Report #250Req
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