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STATE Of CALIFORNIA <br />DEPARTMENT OF FOOD AND AGRICULTURE <br />Chemistry Laboratory Services <br />REQUEST FOR ANALYSIS AND REPORT OF ANALYSIS <br />ON MATERIALS SUBMITTED BY <br />531002 (REV. 3/80) COLLABORATING PUBLIC AGENCIES <br />NOTICE: This form will be returned to you. Please type cr print your addressI LABORATORY NO.— <br />legibly with black ink and fill out form as completely as possible. Date Received <br />Agency NERWIN _B. EBY, Agricultural Commissioner <br />Address P. ®. BOX 18®9 <br />City Stockton (� <br />(Please use address of collaborating agency only) <br />Sampieccns,sts._.--- <br />Use <br />cc Requester , <br />Pesticide Enforcement (2) <br />❑ Check if custody record is required <br />Semple identificaticn marks BCD 1 8 <br />Incation/source of sample STOCKTON AIPI'C)L:T _County SAN JOAOUIN—_- <br />Detailed description of problem OLD DETERIOMTED TAG WITH THIMET AND SKULL AND CROSSBONE <br />-Y'.RC1M rT' H I S AREA - <br />I hereby certify that the analysis requested is necessory in connection v,ith matters relating to my official duties. <br />im- — — ---- --- -- ------I By RAY MAHONEY <br />Saple Pnority Bans for Sample (Alleged Problem) — — -- — — <br />(from Back) <br /># 1 ❑ HumanHealilTitle DEPUTY AGRICULTURAL COMMISSIONE-. <br />+} _ El Plano Symptommssoorr damage ` <br />❑ 3 I ❑ Animal/bee illness/loss Date 12/21/87 <br />—_— -- I ❑ Cnvironmen'al Effects — — <br />Stcrte specific analysis requested laboratory Findings <br />'1' TM1 T <br />RECEWED <br />DEC n 91987 <br />Requested Disposition of Remaining Sample <br />r <br />1 rnlr 11 A QU$P <br />❑ Results Phoned <br />' By <br />Che—st <br />Date TT <br />