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State of 5ralifomia Department of Toxic Substances Control <br /> California Environmental Protection Agen2y AgencyHazardous Materials Laboratories <br /> HAZARDOUS MATERIALS 1.Authorization Number HML No. �2.Page <br /> SAMPLE ANALYSIS REQUEST // ,4 To 6 7CD ��� hof � <br /> 3.REQUESTOR: L ee 1/'t/ 2!� 4.Phone 0!iq : 'Yecx 3X7-5- 7. TAT Level: (check one) <br /> 5.ADDRESS (To Receive Results) � 6.FAX (5-14 <br /> 7 ©49 !rte/4 z. /T✓L_ S i, r -IP O .1 2 3 4 <br /> e--/" 'Unit Chiefs Signature <br /> 8.DATE SAMPLED: 9.Codes (fill in all applicable codes) <br /> 10.ACTIVITY:QfsCD (] SRPD 0 CIB 0 SMB ❑FPB ❑SPPT 0 Others a.Office 0 <br /> 11.SAMPLING LOCATION 1 ry U n I tj 0 b.INDEX Q O <br /> F;,? <br /> a.EPA ID No. c.PCA 2 f <br /> b. Site /-if rl—>? , e/ ;,? i 0' d.MPC <br /> c. Address , fl f f p D e.SITE <br /> Number Street City z/P f.County <br /> 12.SAMPLES: Sample Container <br /> a. ID b.Collector's No. c.HML No. d.T e e.Type f.Size g.Field Information <br /> A l n205 sal, -z a/a{i< fib <br /> 13 <br /> C <br /> D <br /> E <br /> F <br /> 13.ANALYSIS REQUESTED: X desired analysis and enter I.Ds from 12.a.) <br /> INORGANIC ANALYSIS Sample(s) ID ORGANIC ANALYSIS Sam les ID <br /> H CL-Pesticides 8081 <br /> Metals Scan (6010) OP-Pesticides (8141) t <br /> Metal(s)Specific PCBs (8082) .' <br /> WET .+ 14 ,Q G R O 80158 <br /> Cyanides D R O 1 Motor Oil i Both (circle one) <br /> others,write in n-Hexane Extractables 1664 <br /> others;write in Flash Point 1020 <br /> TCLP Analysis VOCs Including BTEX 8260 <br /> (only'f necessa do TCtP regardless) VOCs-LO Level 5035 <br /> Metals VOCs-HI Level 5035 <br /> Mercury SVOCs 8270 <br /> Volatiles PAHs 8270 <br /> Semivolatiles <br /> others,write in others,write in) <br /> 14.ANALYSIS OBJECTIVE: Waste Characterization Treatment Standards <br /> (check a box) Drinking H2O Standards (appfias to 0wonly) Others (contact Lab supervisars'first) <br /> 15.DETECTION LIMIT REQUIREMENTS: <br /> Mecitv it Known and contact fao) <br /> 16.SUPPLEMENTAL Initials <br /> REQUESTS 7 1 1 Date <br /> 17.LAB REMARKS: <br /> 18.CHAIN OF CUSTODY: <br /> 0-2- to iz I X61 ©. <br /> b. 1, l f7 ll L to I C <br /> C. I to I 0 <br /> d. _ I _ to I C <br /> Si nature(s) Name(s) Title(s) Inclusive Dates of Custody <br /> OTSO 1116H (rev r>foo) Make Photocopies for your File NLY <br />