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r n5-a4I <br /> State of California-Health and Welfare Agency � `� �) {',�� Department of Health Services <br /> �t� L 1 Hazardous Materials Laboratory <br /> HAZARDOUS MATERIALS 1. Authorization Wumber HML No. 2. Page <br /> SAMPLE ANALYSIS REQUEST �71y I N & To of / <br /> 3. Requestor : A/p., 1Z Z-eo 4. Phone (411,) S'5s- - 2'1 y Z 5. Priority L� <br /> Address(To Receive Results): C4o17 o4w G.i a' Sint 3 <br /> S (.6 9 6-b 12 a. Authorized by <br /> S/ <br /> 6. Date Sampled 7. Time Sampled Hours 8. Codes (fill in all applicable codes) <br /> ZL� 9 Z <br /> 9.Activity: �3EB <br /> SMB ❑FPB ATD PASD Other a . STC <br /> b. Region <br /> 10. SAMPLING LOCATION i 3 1 6 � I 9 c.TPC <br /> a. EPA ID No. d. INDEX <br /> b. Site L��� ?WE� TA-1 7Cc-� e. PCA <br /> f. SITE <br /> c. Address -/3 Sati✓� f s S7<. ��'�`' 1"S Z�v g. County <br /> Number susie CGry zT <br /> 11. SAMPLES <br /> Sample Container <br /> a. 1D b. Collector's No. c. Lab No. d. Type e. Type f. Size g. Field Information <br /> A )A L h,•T "12 7 9— ( � -S 5 JIM Cite L"--tu S <br /> D I <br /> E EL <br /> F D <br /> G <br /> H <br /> 12.ANALYSIS REQUESTED f . ❑ PCB k.❑ Ext. Org <br /> (Screening) <br /> a. ❑ pH g. ❑ VOA-H/S i. ❑ Flash <br /> Point <br /> b.❑ Metal h.❑ VOA-8240 M. [9 Lw L SLS •>>N <br /> Scan <br /> c.❑ Metals i.❑ VOA-8260 n. ❑ <br /> (Spec) <br /> d. ❑ W.E.T. j. ❑ SVO-8270 0.El <br /> 13. SUPPLEMENTAL ❑ ❑ Initials <br /> REQUESTS <br /> ❑ ❑ Date <br /> 14.a. CH�USTOD <br /> � -�'�L� �f l- 'S ?_Z - S ZG <br /> a. <br /> signature NurrJriUe Ind—ve Due, <br /> b. - <br /> Signaturc Namc/ritk Inrluaivc D.— <br /> c. / / - / 1 <br /> sign Natne/rltic Induuve Duca <br /> d. <br /> Signature T:uncTam wivc Date. <br /> 15. S IAL REMARKS: <br /> 16. ASSIGNED TO: Date <br /> 17. LAB REMARKS: L <br /> _ B <br /> DHS 8002(Rev 10/90) Original-Lab Duplicate-File Triplicate-Inspector NLY(HML) <br />