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Wastewater/Biosolids PFAS Sample Analysis Request
Please complete this form to request PFAS sample kits and analysis.
For more information, please visit
our website
, the
PFAS in biosolids webpage
,
or contact us at
cdphe_wqcd_pfas_grant@state.co.us
. Thank you for your interest!
* Indicates required question
Email
*
Record my email address with my response
Facility Name
*
Your answer
Facility Address (Street, City, Zip code)
*
Your answer
Facility contact name and job title
*
Your answer
Facility contact email
*
Your answer
Facility contact phone number
*
Your answer
Name of facility's legal contact
*
Your answer
Contact information of facility's legal contact
*
Your answer
Type of permit
*
Your answer
NPDESID #
*
Your answer
Intended Sample Date
*
MM
/
DD
/
YYYY
Total Number of Influent Samples
*
Your answer
Total Number Effluent Samples
*
Your answer
Total Number of Biosolid Samples
*
Your answer
Sample site description(s)
*
Your answer
Sample site latitude Decimal Degrees (for each requested sample)
*
Your answer
Sample site longitude in Decimal Degrees (for each requested sample)
*
Your answer
Contact Name of additional people who should receive the final report
Your answer
Contact Email of additional people who should receive the final report
Your answer
Name of receiving water body (wastewater only)
Your answer
Receiving water body ID (Located on your permit; wastewater only)
Your answer
Add the SGEOID number which can be found using the following map (wastewater only):
https://cdphe.maps.arcgis.com/apps/Viewer/index.html?appid=f1541d2f21834642ba1551c674fd4a79
Your answer
A copy of your responses will be emailed to .
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