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State"f t'alifarr is Department of Toxic Substances Control <br /> ifnmia Environmental Protection Agency Hazardous Materials Laboratories <br /> HAZARDOUS MATERIALS 1.Authorization Number H M L No. 2.Page <br /> SAMPLE ANALYSIS RE�Q/UE/S/T% // Jbr To ��� S�� of � <br /> 3. REQUL`ESTOR: L t°d? � !d'_ 4.Phone {,'-i-} '-rr,3,�7j 7. TAT Level: (check one) <br /> 5.ADDRESS (To Receive Results) 6.FAX <br /> 4 l �S t!' ❑ [0 ❑ ❑ <br /> 7JJ A,, :�1 r 4L- A a i� "1 2 3 4 <br /> 13 'tf,-f" z' 'Unit Chiefs Signature <br /> 8. DATE SAMPLED: 9.Codes (FII in all applicable codes) <br /> 10.ACTIVITY:7SCD C:] SRPD ❑ CIB ❑SMH ❑FPS ❑SPPT ❑ Others a.Office <br /> 11.SAMPLING LOCATION / L �4 b.INDEX Q <br /> t— a.EFTA ID No. c.PCA 2 <br /> b. Site /01-1f r? G." /` it h J / d.MPC <br /> 7!0 <br /> c. Address -5', L z, -7 f a d e.SITE <br /> IF <br /> Number Street city ZIP r.County <br /> 12.SAMPLES: Sample Container <br /> a. ID b.Collector's No. c.HML No. d.7y <br /> e e.Type f.Size .Field Information <br /> A (� 0205--19 S r?I- 7 <br /> B <br /> C <br /> D <br /> E <br /> F <br /> 13.ANALYSIS REQUESTED: X desired analysis and enterl.Ds from 12.a.) <br /> INORGANIC ANALYSIS Sam le(s) ID ORGANIC ANALYSIS I Sam les ID <br /> H A CL-Pesticides 8081 <br /> Metals Scan (6010) A OP-Pesticides (8141) <br /> Metal(s)Specific PCBs (8082) _ <br /> WET 14 4. G R O 80158 <br /> Cyanides D R 01 Motor Oil 1 Both (circle one) <br /> (others,write in) n-Hexane Extractables 1664 <br /> others,write in) Flash Point 1020 <br /> TCLP Analysis 0 VOCs Including BTEX 8260 <br /> (oniy if necessary) (do TCLP regardless) VCCs-LO Level 5035 <br /> Metals VOCs-HI Level 5035 <br /> Mercury SVOCs 8270 <br /> Volatiles PAHs 8270 <br /> Semivoiatiles <br /> (others,write in) (others,write int <br /> 14.ANALYSIS OBJECTIVE: Waste Characterization Treatment Standards <br /> (check a box) Ll Drinking H2O Standards (applies to DIN only) Others (contact Lab supervisors first) <br /> 15.DETECTION LIMIT REQUIREMENTS: <br /> (sveeffy rr Known ano contact law <br /> 16.SUPPLEMENTAL Initials <br /> REQUESTS Date <br /> 17.LAB REMARKS: ✓ate 4-5s i y-,7e �U/' I;ZJ j7 /07 k7- <br /> 18.CHAIN OF CU ODY: <br /> I? I/rL�GL A prf3 ! t`J Z to <br /> b. l�s 1 "_ L7 CH A/� i4 r—; ( 2- o 2 to � C <br /> C. _ I to I O <br /> d. —- I to I C <br /> Si natures) Name(s) f Title s) Inclusive Dates of Custodv <br /> DTSC 1116H (REV f✓oo) Make Photocopies far your File NLY <br />