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State of Callfornla—Health and welfare Agent:} - V. Department of Health Seryl,.. <br /> OFFICIAL SAMPLE RECEIPT <br /> HAZARDOUS MATERIALS MANAGEMENT SECTION <br /> 1449 Temple Street 744 P Street 2151 Berkeley Way <br /> Los Angeles, 90028 ` Sacramento, 95814 Berkeley 94704 <br /> (213) 620-2380 (916) 322-2337 (415) 843-7900 <br /> Dat//e <br /> Firm Name <br /> AW IV <br /> Address City Zip Code <br /> e G-Gc TI//�o.n VS 390 <br /> Person Interviewed <br /> Position <br /> ,f} <br /> A/1 U`W�✓f►' <br /> The items listed below were collected as official samples on this date as authorized by Section 66328,California Administrative Code,Title 22. <br /> Quantity Unit Size Material I.D. Number <br /> Tr 1.207- ate/ <br /> Tr <br /> tom'T Sua�. e TFIzo7-coil <br /> A r <br /> t�77WehKFAIT c' <br /> Receipt acknowledged by <br /> By <br /> Signature Authorized Agent <br /> EH 206 (11/79) �� 109944+9 3 M TRIP-OSP <br />