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Slave of California-Health and Welfare agency Department of real.! Ser.,�-!s <br /> HAZARDOUS MATERIALS All applicable items -4ML No 2. Page <br /> SAMPLE ANALYSIS REQUEST rnusr be completed rd �� ,;� fc[Q' <br /> 3. CallettorlAddress �• <br /> to , <br /> fgze' -7 �y7!?� 5. Ptior,ty a i <br /> a.Authorized by <br /> 6 Gate Sampled f p)� 7, Time Sampled f )Hours 8. Codes (fill in all applicable codes) <br /> a. STC n O .a dol <br /> 9.-Acliv+y, ` � Enf;•,I [DSury ❑ Site Mit [S Permitting A'[ TECs [] Other <br /> .wt:str+l4tr L+11Wttidaufam, b. Region .17 <br /> —>i�ImtS'-rcApr:, �1rr - c. TPC <br /> 10. SAINPLiNG LOCATON i <br /> a. EPA ID No i <br /> •'S:� r d. INDEX <br /> d y � <br /> b. Site= , <br /> e. PCA p �� <br /> Y- <br /> C. Address ; / / % �, cc v /.� �O <br /> t,� S N:mcer,. Street Cily Z a g. County O J �f <br /> 11 SAMPL£Sj Container I <br /> b.Collector's No. c•HML No. d. Type e.Type L $ize } g.Field Information <br /> a0 7 0c)1 <br /> Tr 1.207 <br /> d::;i. �.��.,ZD�''C�c rf• C � r .✓fit c /' �,c _ _ - <br /> G. �+�G <br /> H. J <br /> k.❑ Ext. Org E <br /> 12.ANALYSIS REQUESTED f. Cl PCB (Screeng) ; <br /> a. �' 'A'PN ' 5. C] VOA 1- ❑Chlorinated s <br /> / Pesticides <br /> M. Or ano-P <br /> Scan <br /> b.❑Metai' h. 2 PAH w LJ Pesticides <br /> , <br /> c• Metals <br /> �iSPecy i. ❑ Phenols n. <br /> j. C]Carba <br /> d.❑ W.E.T. mates O-L1 I <br /> 0 <br /> 13. CH I OF CUSTODY,,—) /y <br /> L / r r [•, !a• _t '�''3fi rrI' ^•✓rf.4C .i rt 71&E I ?I u <br /> Sig a NadeiT,tie Inclusive Dates <br /> b. <br /> rgn u e , Na.'r Tit e , j tnctuswe Dates <br /> Signa ure ` NarnelTilla Inclusive Dates <br /> _ I <br /> 4. <br /> Signawre <br /> wamerT,;;e Incwxve Dates <br /> 14• SPECIAL REMARKS <br /> 1 <br /> q Ir. <br /> t5. RECEIVED BY � ,�,���• ` a. Title l� ��—� h. Date <br /> 16. SAMPLE ALLOCATION a. .HML-Berkeley b. ❑ HML-SC G. ❑ AIHL d. ❑ Contract b. Dare <br /> • ,- <br /> 17. ANALYSIS REQUESTED .=, <br /> i <br />