Laserfiche WebLink
DepWUr*M of Hew <br /> Servioea <br /> s of Califcmie-Health and Welfare Agency H&nrdo.MomKiella <br /> 1.Authorization Number H No.-1J� t �e <br /> HAZARDOUS MATERIALS -. Ta ar <br /> kMPLE ANALYSIS REQUEST M -3 l 9`` ' d" ;. <br /> 4.Phone(ft'�)Lsr '3f'L 5:Priority <br /> lequestor:A(AVL :�v a,Authorized.byr <br /> Address(To Receive Results): �U�Sy C 47 <br /> 7.Time Sampled Hours 8.Codes(fill in all applicable codes) <br /> 6. Date Sampled 9 <br /> a. sTc 3 0101 <br /> 9.Activity: B•SEB ❑SMB ❑FPB C7. ATD 0 PASD ❑Other Region O <br /> 10.SAMPLING LOCATION <br /> c.TPC <br /> a. EPA ID No. d. INDEX <br /> b.Site (.c7�.�� N'Y�BO O <br /> e. PCA 3 (o <br /> f. SITE <br /> $. c 4'5.2gO g. County O '7 7 <br /> c. Address 213 s city <br /> x� <br /> 11.SAMPLES Sample Container <br /> C. Lab No.l0 i _d.Type G.Type I. Size g.Field Information <br /> a. ID b.Collector's No. <br /> A 8-► -i9-[r.T-sPA izt <br /> 3 0 I Pt <br /> 8 ~i 2- '—U.7� to Z �,�— rs F <br /> C E <br /> D L <br /> E D <br /> F <br /> G <br /> H <br /> f El PCB k.❑ Ext. Org <br /> 12.ANALYSIS REQUESTED (Screening) <br /> i.El Flash <br /> O- <br /> p. 4 �/ g,❑ VOA-H/S Point <br /> a. I�pH <br /> � <br /> , m. ❑ <br /> b,.►� Metal A h.El VOA-8240 <br /> Scan n ❑ <br /> c.❑ Metals i.❑El SVO-8270 VOA 8260 . <br /> (Spec) o.❑ <br /> d.❑ W.E.T. <br /> j. <br /> ❑ Initials <br /> 13.SUPPLEMENTAL ❑ <br /> REQUESTS ❑ Date <br /> ❑ I <br /> 14.CHIN OF CUSTOS �/ ('p,^ ��e ,�2f�iir 1 <br /> a. <br /> S, <br /> b. s - <br /> C. x­Vrua / - Z <br /> s� / <br /> Indus,—D•N <br /> d. xsme/r ule <br /> 5 i�soue <br /> 15.SPECIAL REMARKS: I <br /> Date <br /> 16.ASSIGNED TO: L <br /> A <br /> 17.LAB REMARKS: B <br /> Original-Lab Duplicate-File Triplicate-inspector <br /> NLY(HML) <br /> JHS 8002(Rev 10/90) �_ <br />