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Co of Pu b iccQ
<br />and Environment
<br />REQUEST FOR ANALYTICAL
<br />CUSTOMER
<br />CustomerlD :
<br />Name:
<br />Address :
<br />City /St/Zip :
<br />Phone :
<br />Email:
<br />Contact :
<br />Fax:
<br />PWS ID: COO
<br />System Name:
<br />Address:
<br />Description:
<br />Laboratory Services Division
<br />8100 Lowry Boulevard, Denver, CO
<br />US Mail: PO Box 17123, Denver, C(
<br />(3031692 -3090 fax (303) 344 -99
<br />00009830
<br />Department of Natural Resources
<br />1313 Sherman Street Room 215
<br />Denver CO 80203
<br />303 - 866 -3567
<br />Berhan Keffelow
<br />5o UV V
<br />Location
<br />un
<br />Source
<br />ae
<br />Sy stem ID
<br />Collection Date
<br />Control Number
<br />Fluoride
<br />r
<br />SAMPLE SITE
<br />❑Real Estate /HUD (Coliform Bacteria,
<br />Lead, Nitrate and Nitrite)
<br />❑Annual Colorado Package
<br />(Coliform Bacteria, Nitrate /Nitrite)
<br />❑Expanded Annual C orado
<br />Package (Coliform Bac ria,
<br />Nitrate /Nitrite, pH, IDS
<br />❑General Colorado P kage
<br />(Arsenic, Coliform Bact a, 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 />❑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 />RELINQUISHED BY:
<br />RELINQUISHED BY:,
<br />COMPLIANCE DRINKING WAT TESTS
<br />Omani C mi . I le
<br />❑EDB /De '
<br />❑Ch . ' ate. ides ;
<br />Pes
<br />con tr
<br />h , ted Herbicides
<br />_olatile _Organic - Compounds- (VOCs) - --
<br />❑Semivolatile Organic Compounds (SVOCs)
<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 T1) + 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 />Disinfection Byproducts
<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 Rule (Microbiology /Bacteria)
<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 />SPECIMEN INFORMATION
<br />DATE/TIME:
<br />DATE /TIME:
<br />DATE /TIME:
<br />Inorganic Parameters
<br />❑Alkalinity
<br />❑ BOD ❑CBOD ODO
<br />❑ Chemical Oxygen Demand (COD)
<br />❑ Chloride
<br />❑ Chlorine
<br />OChromium, +e ) '
<br />❑ i sivity (Langlier)
<br />❑ Direct ❑ Distilled
<br />WAD
<br />Fluoride
<br />D Hard ness
<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 />0 p
<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 />RECEIVED BY:
<br />RECEIVED BY:
<br />RECEIVED BY:
<br />Collected by.
<br />Purpose:
<br />LSD Interent Address: http://www.cdphe.state.co.us/Ir/lrhom.htm Report #250Req
<br />Collected: laj
<br />month day year
<br />Chlorine residual: rJ B rio . mg /L
<br />Temperature at Receipt:
<br />Comments:
<br />ENV - 2011007891
<br />7/14/2011 12:00:OOAM
<br />31
<br />LJL 1ti 1
<br />Time
<br />hour
<br />Water Type:
<br />Routine El Special Purpose
<br />ompliance J Personal Information
<br />a LEE mg /L
<br />/t( G
<br />Water Temperature
<br />m oc
<br />Organic Parameters
<br />❑ Oil and Grease
<br />❑VOCs Screen
<br />❑SVOCS /Pesticide
<br />Screen
<br />❑BTEX
<br />Radiochemis try
<br />❑Gross Alpha /Beta
<br />['Radium 226
<br />❑Radium 228
<br />❑ Uranium
<br />❑C -14
<br />❑Radon
<br />❑ N i -63
<br />❑Gamma Spectromel
<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 />DATE/TIME:
<br />DATE/TIME:
<br />DA3 /TIM /v
<br />.a�
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