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State of California <br />•Califomia Environmental Protection.Acencv <br />16 Department of Toxic Substances Control <br />Hazardous Materials LaboratoriPc <br />HAZARDOUS MATERIALS <br />SAMPLE ANALYSIS REQUEST <br />Authorization Number <br />HML No. <br />To <br />2. Page <br />of <br />X11. <br />rT <br />3. REQUESTOR: �- G� o �<C 1.s Z _4.Phone J �p - 3 ?S <br />7. TAT Level: (check one) <br />5. ADDRESS (To Receive Results) 6. FAX <br />(iia 53,0 <br />�c/ c <br />!, <br />� � 7 <br />* 1 2 3 4 <br />` Unit Chiefs Signature <br />/s N <br />0 g2 Ale— /'_2 Z �iy� ✓�U. �G � Od <br />,% <br />-- 1 619- Q <br />8. DATE SAMPLED: <br />9. Codes (fill in all applicable codes) <br />10. ACTIVITY: 93"SCD ❑ SRPD! ❑ CIB ❑ SMB ❑ FPB <br />❑ SPPT ❑ Others a. Office 0 s� <br />11. SAMPLING LOCATION CI A JZ- 0 1 :5> p <br />/ b. INDEX j> <br />a. EPA ID No. c. PCA <br />b. Site CD <br />le,lT� d d. MPC <br />c. Address V4 Ide,- 5 / f e. SITE <br />Number Street City <br />ZIP7c�Z�,' 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 Q. Field Information <br />A 7' d C�`Z 6 <br />So .` a v s <br />B <br />C <br />D <br />E <br />F <br />13. ANALYSIS REQUESTED: <br />X desired anal sis and enter I.Ds from 12.a. <br />INORGANIC ANALYSIS Sam les ID <br />ORGANIC ANALYSIS SamplesID <br />H <br />CL -Pesticides 8081 <br />Metals Scan (6010) <br />OP -Pesticides (8141) <br />Metal(s) Specific <br />PCBs (8082) <br />r� <br />WET ;24' /7 e e r. !T <br />G R O 80158 <br />Cyanides <br />D R O / Motor Oil I Both (circle one) <br />others, write in <br />n -Hexane Extractables 1664 <br />others, write in <br />Flash Point 1020 <br />TCLP Analysis a Q <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 />PAI -Is 8270 <br />Semivolables <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 />(specry U Known and contact lab <br />16. SUPPLEMENTAL <br />Initials <br />REQUESTSLi <br />Date <br />17. LAB REMARKS: /{y Ga <br />�/ J/ <br />OL <br />18. CHAIN OF CUSTODY: , / <br />g <br />b. <to _ �,, C-f�A�c/ <br />( 7 <br />ZZ <br />ft PH C — t - 161 n L to I <br />C <br />C. <br />to <br />o <br />d. <br />( I to <br />C <br />Signatures Name(s) / T-Itle Lsj Inclusive Dates of Custody <br />DTSC 11161-1 (REV 6100) Make Photocopies for your File NLY <br />