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State of California-Health and Welfare Agency Deparwwnt of Health Services <br /> Hazardous Matenals Laborakxy <br /> HAZARDOUS MATERIALS 1.Authorization Number HML No. I lq(p (7p 2-Page- <br /> SAMPLE ANALYSIS REQUEST H I M )4 1 / I 7.,.. To ,FELE of <br /> 3.Requestor:.4/4.1 tc_ 4.Phone(ft ItS.r -7T& 5-Priority Ll ' <br /> Address(To Receive Results):/,, ....a....,a..Authorized by,` �• `' `� <br /> v S t. 3 CI.c- �1 I <br /> 6. Date Sampled �L,LI L " 7:Time Sampled Hours' 8-Codes(filljallpplicable codes}. <br /> 3_,V i <br /> 9.Activity: -FEB ❑SMB ❑FPB: . ,. O ATD ❑PASD,. _D Other• <br /> a'.STC 1" <br /> - b:Region.- <br /> 10. <br /> egion. <br /> 10:SAMPLING LOCATION J j) 13 6 .� y : c-TPC t <br /> . , a:EPA ID No. , . _ct INDEX' <br /> b Site �6 d�. A C-7a-L e. PCA <br /> - f. SITE <br /> c.Address Z 13 -So"-'4A 161L SI_ .LocCc g" County <br /> N.. City zip, <br /> 11.SAMPLES <br /> Sample Container <br /> a- ID b.Collector's No. a Lab No: d:Type e:Type, f: Size, g.Feld lriformation " <br /> A LN,Ty z 71- 1 t t•Ct.� ♦ s s <br /> B cwT447s� L� �U dy` l� r>- <br /> C- 4-%-A t 171-2-b- ��t--J .s �.._ r s __ F <br /> D - <br /> l <br /> E E <br /> F D <br /> G <br /> H <br /> 12-ANALYSIS REQUESTED t. ❑PCB k.❑ Ext.Org - <br /> (Screening) <br /> a. [X pH g.❑ VOA-H/S i.❑ Flash <br /> Point <br /> b. Metal h.❑ VOA-8240 m, ❑ <br /> Scan <br /> c. Metalsj4 q i.❑ VOA-8260 n. ❑ <br /> (Spec) <br /> d.ElW.E.T. j. ❑ SVO-8270 0,El <br /> 13.SUPPLEMENTAL ❑ Initials <br /> REQUESTS <br /> ❑- Date <br /> 14. CU <br /> CHAIN O �� S Z Z_ <br /> a. (,l� <br /> s tr Dom- <br /> /-/,( <br /> b. � � Nm✓rm. �.+Ds <br /> C. <br /> Sime N radon+D. <br /> d. / / - / / <br /> s NowTal. hi—Dm <br /> 15.SPECIAL REMARKS: <br /> 16.ASSIGNED TO: Date <br /> 17.LAB REMARKS: L <br /> A <br /> B <br /> DHS 8002(Rev 10/90) Original-Lab Duplicate-File Triplicate-Inspector NLY(HML) <br />