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De�ant of Heath Sarv+eec <br /> :t Califorr+l�-;1wittt and Wdlne AQency , _Hs=rdoua.Mownsis.LabOralOD' <br /> HIL Na.961 o Z pop r <br /> HAZARDOUS MATERIALS 1.Autttonzatbn Number 'j�'`cf'- <br /> 'CE ANALYSIS REQUEST M :S l <br /> Com` LSr -D�.L 5.Priority ..•s .t - �:-M ;,.. <br /> 4.Phone ) L` <br /> idress(To Receive Results):/0(SI ` z 7 <br /> Co <br /> Hours B. des(fill in all app <br /> .Tllicable• <br /> 7me Sampled � <br /> 6.Date Sampled �� a. STC 3 D �� <br /> 9 4ty; j21tB 0 SMB ❑FPB ❑ATD 0 PASD ❑Other b Rion O - ? <br /> c.TPC <br /> SAMPLWG LOCATION <br /> a. EPA ID No. d. INDEX <br /> 7e e. PCA 3 (o p O <br /> b. Site ��'� e t. SITE <br /> Count �! <br /> ,S. �r5.2�/O 9• Y 0 7 7 � <br /> c. Address a�3 C� zW <br /> s <br /> SAMPLES Sample Container <br /> d.Type e. Type t. Size g. Field Information <br /> a. ID b. collector's No. c. Lab No. n <br /> A 8- I�-i9-lG•.T- `LI vt• <br /> 2-2,k •-L,.7r5 lOSZ rs F <br /> I <br /> c -- <br /> E <br /> D L <br /> E D <br /> H <br /> k.❑ Ext. Org <br /> 12.ANALYSIS REQUESTED <br /> f . ❑PCB (Screening) <br /> g.❑ VOA-H/S i.❑ Flash <br /> _,/ Point <br /> a. 4� pH <br /> Metal ❑ VOA-8240 <br /> b,B <br /> m. ❑ <br /> Scan n. ❑ <br /> i.❑ VOA-8260 <br /> c.❑ Metals <br /> (Spec) 0.❑ <br /> d.ElW.E.T. j, ❑ SVO-8270 <br /> ❑ Initials <br /> 13.SUPPLEMENTAL ❑ <br /> e <br /> REQUESTS ❑ Dat <br /> 14.CHQI COSTO _ �/ �,�o�+ / Dj/�/�/► q �,�. io.e, <br /> a. <br /> 01 <br /> pQ lyt 1,o�y, 1 I � - <br /> b. �� N.L.rrm. � / / <br /> s,w.o.• l/ <br /> C. N.me/fab / z 1 <br /> Sv tnuur.�Dees I <br /> ---------------------- <br /> d. <br /> Dees <br /> 15.SPECIAL REMARKS: I <br /> AA �� Date ✓� <br /> ASSIGNED TO: /"tom L <br /> A <br /> 17. LAB REMARKS: B I <br /> i <br /> NLY(HML) I <br /> Anginal-Lab Duplicate File Tnpbcate-Inspector <br /> QHS 8002(Rev 10/90) - <br />