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.. .1. r► Hw0I1h$swam <br /> page <br /> r <br /> HAZARDOUS MATER'ILS 1•Auihonzabn Number <br /> f r <br /> AMPLE ANALYSIS REQUEST A Z. = <br /> tequestor:MA.- -4L) 4. Phono(Sr�)LSr _ J4.1. ic I c blc-xs <br /> ddress(To Receive Results): /U/S/ L7 <br /> 6. Date Sampled <br /> 7.Time Sampled Hours a_Carlos(fill in all appiicabio.c�doa) <br /> / G� � O k <br /> a. STC -T 0 - <br /> � <br /> 9.Activity: 5EB C SMB ❑FPB C3ATD O PASD :3 Other b. Region 4 <br /> SAMPLING LOCATION c TPC <br /> a. EPA ID No. d. INDEX <br /> b. Site <br /> WGE �1 PCA 3 (o S O D <br /> f. SITE <br /> ��3 S "z"/.` crSa 4O g• County IO I7 7 <br /> c. Address <br /> Nu�a <br /> s n, � <br /> 1. SAMPLES Sample Container <br /> b. Collector's No. <br /> tc. ab No. d-Type e. Type f. Size g. Field Information <br /> IDA s- , -��-C10B i 2 u•7�'S $Z' -- r s -- F <br /> C I <br /> E <br /> L <br /> E D <br /> G <br /> H <br /> f . ❑ PCB k.�� Ext. Org <br /> 12.ANALYSIS REQUESTED (Screening) <br /> Z,-- <br /> �/ r� O g•❑ VOA-H/S I U Pant <br /> a. Z pH <br /> �,/ P, ` h•❑ VOA-8240 M. ' <br /> b. Metal <br /> ScanVOA-8260 n• <br /> '—' <br /> c.❑ Metals <br /> i.[] <br /> I <br /> (Spec) <br /> I <br /> d.❑ W.E.T. . SVO-8270 ° <br /> Initials <br /> 13.SUPPLEMENTAL <br /> REQUESTS ❑ Date <br /> 14. CH I/�N OF CUSTO n E, / may / /d <br /> a. <br /> rc I <br /> b. N"Wrak <br /> i <br /> C. N—araw <br /> �o...D— <br /> SU <br /> 15. SPECIAL REMARKS:77 <br /> I <br /> Date <br /> 16.ASSIGNED TO: L I <br /> 17.LAB REMARKS: A <br /> B <br /> NLY(HMLl <br /> _,HS 8002(Rev 10/90) Onpinw-Lab Dull-te-Elie Tnoicate•-Insoecto, <br />