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State of al'sfomia Department of Toxic Substances Control <br /> -C-31 cmla Environmental Protection Agencv Hazardous Materials Laboratories <br /> HAZARDOUS MATERIALS 1.Authorization Number HML No. 2.Page <br /> SAMPLE ANALYSIS REQUEST 7o d 0 "Z-:, at <br /> 3.REQUESTOR:_- --L ev t/�L 4.Phone 0 lZ3 S'J"67 7. TAT Level: (check one) <br /> 5.ADDRESS (To Receive Results) 6. FAX (,jm �_ <br /> 7�20 Y,-/az C _ .-L r —lP i5-7Oo '1 2 3 4 <br /> !a ti/'f 'Unit Chiefs Signature <br /> 8. DATE SAMPLED: el 9.Codes (fill in all applicable codes) <br /> 10.ACTIVITY:LytSCD ❑ SRPD ❑CIH ❑SMB ❑FPB ❑SPPT ❑ Others a.Office � L <br /> 11.SAMPLING LOCATION [> Q 6.INDEX Q <br /> r a.EPA 10 No. c.PCA '-,,— /f / <br /> b. Site ` ✓ d.MPC <br /> c. Address , L Q 7 Af d 1) e.SITE <br /> Number Street City Z1P "•.f.County 3 <br /> 12.SAMPLES: Sample Container >� <br /> I <br /> a.ID b.Collector's No. c.HML No. d.Type e.Type f.Size q. Field Information <br /> A Cil 1 1 1 [�L� .S o% ale.Li 9z,ZQlTfvJ, -2, <br /> B �)0 5 Q .50 3w Qs TI- <br /> C <br /> D <br /> E <br /> F <br /> 13.ANALYSIS REQUESTED: desired analysis and entaf l.Os from 12.a.) <br /> INORGANIC ANALYSIS II Sample(s) ID ORGANIC ANALYSIS Sam les ID L <br /> H IA, CL-Pesticides 8081 <br /> Metals Scan (6010) A OP-Pesticides (8141) <br /> Metal(s)Specific PCBs (8082) : <br /> WET r G R O 80158 <br /> Cyanides D R O 1 Motor Oil 1 Both (circie ane) <br /> (others,wnte in) n-Hexane Extractables 1664 <br /> others,write in) Flash Point 1020 <br /> TCLP Analysis VOCs Includin BTEX 8260 <br /> (ordy if necessary) do TCLP regardless) VOCs-LO Level 5035 <br /> Metals VOCs HI Level 5035 <br /> Mercury SVOCs 8270 <br /> Volatiles PAHs 8270 <br /> Semivoiatiles <br /> others,write in) - I (others.write in) <br /> 14.ANALYSIS OBJECTIVE: I LLW-ste Characterization Treatment Standards <br /> (check a box) Li Drinking H2O Standards (applies to Dwonly) Others (contact Lab supervisors first) <br /> '15.DETECTION LIMIT REQUIREMENTS: <br /> (speciTy it known and contact iab) <br /> 16.SUPPLEMENTALLj Initials <br /> REQUESTS Date <br /> 17.LAB REMARKS: �T 121 <br /> 17102— /'� <br /> 18�101 DY: <br /> b. At - H -/l L 1 <br /> I1 o2 to I C <br /> c. I to + O <br /> d- to I C, . <br /> Si natumfs) Name(s) / Trtle(s) Inclusive Dates of CustodvI f <br />