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<br />LaboratonL-S
<br />8100 Lo ENV-2011001851
<br />US Mail: System ID
<br />2/17/2011 11:55:OOAM
<br />(303) 69 Collection Date
<br />Control Number 4
<br />REUEST FOR P-.immi- I I K AL SERVICES Collection No: [111 ? ? E
<br />,iCUSTOMER INFORMATION
<br />CustomerlD : 00009830
<br />
<br />Name : Department of Natural Resources
<br />
<br />Collected:
<br />n
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<br />- T Time I / I
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<br />Address : 1313 Sherman Street Room 215 mon h day year
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<br />City/St/Zip : Denver CO 80203 Collected by : Water Type:
<br />Phone : 303-866-3567 Purpose: Routine Special Purpose Repeat
<br />Email:
<br />Contact : $erhan Keffelow Compliance E] Personal Information
<br />Fax:
<br />SAMPLE SITE Chlorine res idual: mg/L Water Temperature ?n D
<br />C
<br />PWS ID:
<br />coo FIE] 11 1111 ? [I
<br />Fluoride
<br /> ., [1 .11011 mg/L
<br />System Name:
<br /> Temperature at Receipt:
<br />Address:
<br />CID
<br />
<br />Comments:
<br />City oun State
<br />- --
<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 />?An ual Colorado Package ?EDB/DBCP ? BOD ?CBOD []DO ?VOCs Screen
<br />(Colif m Ba
<br />) ?Chlorinated Pesticides []Chemical Oxygen Demand (COD) ?SVOCS/Pesticide
<br />?Ex nde []PCBs (Subcontracted) []Ch
<br />loride
<br />Screen
<br />Pack ?(CO rm ?Chlorinated Herbicides Chlorine _?{?TEX
<br />Nitrat Nitri - -6VotatiteOrganic Compounds (VOCs) []Chromium, hexavalent (Cr+6) Radiochemistry
<br />?Ge eral ora
<br />k ?Semivolatile Organic Compounds (SVOCs) ?Corrosivity (Langlier) []Gross Alpha/Beta
<br />(Arsenic, Co ness, ?Carbamate Pesticides Cyanide ? Direct ? Distilled []Radium 226
<br />Copper, Flu e, ?Diquat (Subcontracted) ? WAD []Radium 228
<br />Nitrate/Nitrit ra ?Endothall []Fluoride []Uranium
<br />
<br />[]Deluxe C
<br />k
<br />?Glyphosate
<br />[]Hardness
<br />OC-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 Spectrometn
<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 d []Magnesium
<br />Adsorption Ratio, Sulfate, Total Lead and Copper Rule []Man ane []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 in []Fat
<br />Cadmiun, Copper, Iron, Lead, []Radium 226 ? ungsten []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 />Sulfur, and Uranium) []Total Coliform (Present/Absent, w/ E. coli) ' c 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) ?Su I e
<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, Molybdenum
<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: DATE/TIME:
<br />RELINQUISHED BY: DATE/TIME:
<br />it F
<br />RECEIVED BY:
<br />'Wh
<br />
<br />DATE/TIME:
<br />?-L
<br />LSD Interent Address: httpJ/www.cdphe.state.co.us/Ir/lrhom.htm Report #250Req ?? ?
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