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Slate of Cahfoenla—Heellh end Welfare Agency Department of Heatih Semcea <br /> REGION I OFFICIAL SAMPLE RECEIPT REGION 3 <br /> Sacramento, <br /> Croydon Way 1405 N. San Femando Blvd. <br /> ento, CA 95827 Burbank. CA 91504 <br /> (916)855-7700 TOXIC SUBSTANCES CONTROL PROGRAM (818)567-3000 <br /> REGION 2 REGION 4 <br /> 700 Heinz Avenue. Suite 200 245 W. Broadway, Suite 305 <br /> Berkeley, CA 94710-2737 <br /> (415)540-2122 Long Beach. CA 90802 <br /> (213)590-4888 <br /> Ptw Nem, <br /> Date <br /> v �U ✓r"1 U - �. l � <br /> � _ ? t3 <br /> Adareaa <br /> r, clry ! ZIP case <br /> Person IntervkvW <br /> jj //'� Poaltlon <br /> The items listed below were collected as official samples on this date as authorized by Section 66328, <br /> California Code of Regulations, Title 22. <br /> Quantity Unit Size Material In Number <br /> � �7a�• 1 r 7 <br /> O � e4 <br /> n <br /> Receipt acknowledged by: <br /> By <br /> Stgnalvre An(horizea Agent <br /> Ell 2M f5/911 <br />