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DustomerlD : 00009830 1 <br />Collected: I <br />I� _ �� _ <br />_ L <br />1 ' <br />Time 1 <br />1 / <br />/ 0 <br />0 � <br />', a.m <br />ion h i <br />, da year hour m n .-- <br />City /St/Zip : D <br />Denver C <br />CO 8 <br />80203 <br />_ F <br />Purpose: ❑ Routine S <br />■ 9 <br />0 P <br />Special Purpose D R <br />Repeat <br />iystem Name: �- T <br />Temperature at Receipt: <br />Colorado Dcparrmcnt <br />of Public Health <br />and Environmcnt <br />Laboratory Services Division <br />8100 Lowry Boulevard, Denver r.o R093n - RQ <br />US Mail: PO Box 17123, Deny <br />(303) 692 -3090 fax (303) 3. System ID <br />Collection Date <br />Control Number <br />REQUEST FOR ANALYTICAL <br />CUSTOMER <br />LSD Interent Address: http:// www .cdphe.state.co.us /lr /lrhom.htm Report #250Req <br />ENV - 2011007889 <br />7/14/2011 11:40:OOAM <br />79 <br />SPECIMEN INFORMATION <br />