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—Stago Califomia= <br />r`.,I:F�m:., C...,:.°,.,mon+�l Prn4cr-Finn Gnanry <br />Oepartment of Toxic Substances Control <br />Hazardous Materials I Rhnrntnripc <br />HAZARDOUS MATERIALS 1. Authorization Number <br />SAMPLE ANALYSIS REQUEST <br />HML No. Qj�j --t 2. Page <br />To <br />3. REQUESTOR: 4- L' oy e' l�C z 4. Phone(�/p) J �p -3?S <br />7. TAT Level: (check one) <br />Results) 6. FAX <br />5. ADDRESS (To Receive Results) <br />,c/ C <br />!'' <br />El [E' <br />`1 2 3 4 <br />. Unit Chiefs Signature <br />//.S <br />NN <br />70e9 <br />:Z00 <br />Q , 1 l� G.� Q <br />8. DATE SAMPLED: <br />9. Codes (fill in all applicable codes) <br />, <br />10. ACTMTY: E SCD ❑ SRPD E:1CIB El SMB ❑ FPB <br />F-1ffi <br />SPPT ❑ Others a. Oce 01, <br />11. SAMPLING LOCATION C L O 1 e2 Q <br />b. INDEX jJ <br />a. EPA ID No./ G PCA to 2 <br />/� © / <br />b. Site a C , n J le, T�v d. MPC <br />c. AddressVic IGe r L/tel cv S / e. SITE <br />Number Street City ZIP C1d 1.e25 f. County 3 <br />12. SAMPLES: <br />Sample Container <br />a. ID b. Collector's No. c. HML <br />No. d. T e e. Type f. Size o. Field Information <br />A 7`I C1 I D2 Q <br />0/zz a 910 S <br />B <br />_ <br />C <br />D <br />E <br />F <br />13. ANALYSIS REQUESTED: <br />desired analysis and enter l.Ds from 12.a.) <br />INORGANIC ANALYSIS SaM12�sj, ID <br />ORGANIC ANALYSIS Sam les ID <br />Fi <br />CL -Pesticides 8081 <br />Metals Scan (6010) <br />OP -Pesticides (8141) <br />Metal(s) Specific <br />PCBs (8082) <br />WET <br />G R O 8015B <br />Cyanides <br />D R 0 / Motor Oil / Both (circle one) <br />others, write in <br />n -Hexane Extractables 1664 <br />others, write in I <br />Flash Point 1020 <br />TCLP Analysis a 0 <br />VOCs Including BTEX 8260 <br />(only if necessary) (do TCLP regardless) VOCs - LO Level 5035 <br />Metals <br />VOCs - HI Level 5035 <br />Mercury <br />SVOCs 8270 <br />Volatiles <br />PAHs 8270 <br />Semivolatiles <br />others, write in <br />others, write in <br />14. ANALYSIS OBJECTIVE: <br />Waste Characterization <br />Treatment standards <br />Drinking H2O Standards (applies to DW only) <br />Others (contact Lab supervisors first) <br />(check a box) <br />15. DETECTION LIMIT REQUIREMENTS: <br />(sp2= it known and contact tab <br />16. SUPPLEMENTAL <br />Initials <br />REQUESTS <br />Date <br />17. LAB REMARKS: <br />7 <br />02- <br />18. CHAIN OF CUSTODY: <br />a.-.�ltL. �— L /J t� 4 <br />b. f_ '' f Kuo - l+n IC_i <br />/l � /� Ir S �,�,,I JJ I �2 to <br />If`�A/V CT Et t C `-Tkk# /6I O 'i_ to I <br />C <br />C. <br />d. <br />! to I <br />to <br />O <br />C <br />Si natures Name(s) / Tiiles) Inclusive Dates of Custody <br />