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oding Wastewater/Biosolids PFAS Sample Analysis Request
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!
Email *
Facility Name *
Facility Address (Street, City, Zip code) *
Facility contact name and job title *
Facility contact email *
Facility contact phone number *
Name of facility's legal contact *
Contact information of facility's legal contact *
Type of permit *
NPDESID #  *
Intended Sample Date *
MM
/
DD
/
YYYY
Total Number of Influent Samples *
Total Number Effluent Samples *
Total Number of Biosolid Samples *
Sample site description(s) *
Sample site latitude (for each requested sample) *
Sample site longitude (for each requested sample)
 *
Contact Name of additional people who should receive the final report
Contact Email of additional people who should receive the final report
Name of receiving water body (wastewater only)
Receiving water body ID (Located on your permit; wastewater only)
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
A copy of your responses will be emailed to .
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