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State of Califomia—Health and Welfare Agency Department of Health SeMtes <br /> REGION I OFFICIAL SAMPLE RECEIPT REGION 3 <br /> 1405 N. San Fernando Blvd. <br /> 101St Croydon Way <br /> Burbank, CA 91504 <br /> Sacramento. CA 95827 <br /> m <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 Long Beach, CA 90802 <br /> (415)540-2122 (213)590-4868 <br /> Date <br /> Firm Name <br /> Address city ZIP Code <br /> JTAJ <br /> Peraon InteMewed �� Poeltlon <br /> I 1 <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 ID Number <br /> ,, id ('-mtdo!a Jai 15 <br /> Receipt acknowledged by: <br /> By <br /> Signature Authmfeed Aamt <br /> EH 205(5/91) <br />