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a of CaWomwHeaith and Welfare Agency Department of Heakh Services <br /> Haardous Mataroh:Laboratory <br /> 1.Authorization Numbee HMtNo_Q �L��p 2-Pa9o- <br /> HAZARDOUS MATERIALS. �P <br /> SAMPLE ANALYSIS REQUEST N �. �, III <br /> » ea <br /> Re4utor:g/d•t �- �'�'� ski Phon4 N►�)WSJ- -7 7�_ _. _ g` a ..ti. . _ ri. li <br /> Addre"(TO Receive Fkm ts)./v/S/ V S..�f+ S S�w� CJYJ l�t�' �3 AlrttlOrlZY�+� <br /> 6_Date Sampled �7L'L/4 L _ 7-_11me Sampled. - Hours- . >LCodes(fig imalLapQlicabiocodes)r •.'„ <br /> +-ry <br /> STC <br /> 9.Activity: Cr8EB 0 SMB 0 FPB. 0 ATT) O PASD' QOthat^ br.FiagtO <br /> i <br /> 1QSAMvuNCLocATTOF! A. D' $' G 3 (, g' 4 i:-TFC <br /> n}• ..•4..:anEPA-ID'No•_ (f-INDEX' - <br /> ?ECf4. ei PCA- <br /> f. <br /> CA f.SITE- <br /> c- <br /> ITEc-Address So <br /> Zf3L..'_... s _ .LecLc g.County <br /> •` <br /> 1.1.SAMPLES = J Container+ ':�•�:: : �" , 9 <br /> Sample _. .. . <br /> d�T a e:.T h.Siz� ' Fiekt-I iformation <br /> a-ID b_Collectors No: �Cab Na.; YP Ypeg` <br /> �-.. <br /> A L 7t ,r — <br /> ►%T'4 _ ,Z <br /> B c_wTYL71, L ;: �l..,Ly` iL CY_ � { _. -- <br /> C <br /> 4-1..n i t{L 71- 7 A•- d C.r1 i s I -ts- ?' S F <br /> E it <br /> D <br /> F <br /> G _ c: .... <br /> 12 ANALYSIS REQUESTED f. ❑PCB Q Ext: g <br /> (screenn ing <br /> ��p g.Q VOA-H/S i.❑ Rash <br /> Point <br /> b.SQ Metal h.Q VOA-8240 m M <br /> Scan_ <br /> G9 Metals j-�a i.Q VOA-8260 n Q <br /> _ <br /> (Spec) <br /> d.Q.W.E.T. j. Q SVO-8270 0.❑ <br /> 13 WPPLEMENTAL Q <br /> � Initials �� <br /> REQUESTS Q. Date< <br /> 14.CHAII 0 C f'Lf�jjy S t z_ <br /> a_b. <br /> sty+.- x..rrrr- �•. � - � ,!�`- <br /> � Y�n/I'L1r bechrn.D.� <br /> /• _ l <br /> d. hmd�Do—- <br /> 15-SPECIAL REMARKS- <br /> 1&ASSIGNED TO: Date _ I <br /> L <br /> 1T.LAB REMARKS: A <br /> B <br /> DHS 8002(Rev 10/90) <br /> prignaHab - Dup&cat -Filer- Trip6cate4nspector NLY(HML). <br />