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Stale of California-Health and Wellare Agency .s 4 Department of Hea sh Services <br /> HAZARDOUS MATERIALS All applicable items 1. HML No., 2, Page <br /> SAMPLE ANALYSIS REQUEST must be completed To (�� C!(� of / <br /> 3. Collector/Address . oV 73 —3q 8O <br /> _ ��,� 4Phone { 1 <br /> � 5. Priority <br /> FX ®, <br /> a. Authorized by <br /> 6. Date Sampled /a p'] 8 7. Time Sampled /,S S]Hours 8. Codes (fill in all applicable codes) <br /> �vt a. src 2t%l <br /> 9. Activity D Ent ❑ Sury ❑ Site Mit ❑ Permitting ❑ Ail Tech ❑ Other <br /> b. Region <br /> 10. SAMPLING LOCATION � 0 � � A N � c. TPC <br /> a. EPA ID No. <br /> � � d. INDEXb. Site e. PCA <br /> c. Address &/ 7 I. SITE <br /> Number Street City zip g. County Io 3 <br /> 11, SAMPLES Container <br /> a. 1,P b.Collector's No. c.HML No, d. Type e.Type I. Size g. Field Information <br /> J'F 1,207 _-CV3 1Z 01 L le- <br /> 170. J•Fl�o7��`�_ 5' u � F <br /> E• ,TF I.qC7 -OCT �� 5 7 (n- I <br /> TFI;zo? E <br /> G. t L <br /> D <br /> H, <br /> k.❑ Exl. Org <br /> 12.ANALYSIS REQUESTED I. ❑ PCB (Screeng) <br /> a. 0 pH 7 L ❑Chlorinated <br /> 9• ❑ VOA Pesticides <br /> b. ❑Metal m. ©Organo-P <br /> Scan h. PAH Pesticides <br /> c. x Metals i ❑ Phenols n. ❑ <br /> {spec) A b' C, . �. F . <br /> j. ❑Carba- <br /> d.❑ W.E.T. males ° ❑ <br /> 13. CH 1)F CLISTOC v0 � , �+ �ie�J�� <br /> � � s <br /> Sigi a Na a/Title / / / Inclusive Dates <br /> b. <br /> gn u e +' Na Tile Inclusive Dates <br /> signature Name/Title Inclusive Dates <br /> d. <br /> Signature Name/Title Inclusive Dates <br /> 14. SPECIAL REMARKS <br /> 15. RECEIVED BYa. Title b, Date _ <br /> - J r �� <br /> 16. SAMPLE ALLOCATION a. .HML-Berkeley b. ❑ HML-SC c. ❑ AIHL d. ❑ Contract b. Date <br /> 17. ANALYSIS REQUESTED A <br /> o <br /> nH.¢Rnng ORP„7/a7% , <br />