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' � 4 <br /> ► °"`"`0+,y STATE OF CALIFORNIA—ENVIRONMENTAL PROTECTION AGENCY <br /> • REGIONAL WATER QUALITY CONTROL BOARD <br /> . CENTRAL VALLEY REGION C�HZUM (DIP c <br /> + 3443 ROUTIER ROAD,SUITE A • SACRAMENTO,CA 95827-3098 j <br /> PHONE: (916)255-3000 • FAX (916)255-3015 � <br /> PROGRAM PCA 324(-16 PROJECT <br /> NAME � , ANALYSIS REQUIRED colvoirlorrs <br /> T S tJl I�Ctl�4Q f( P..WHO.ETG.1 <br /> OWL' '"\" <br /> I <br /> SAMPLER (Signature) PRINT NAME ua <br /> I <br /> Uj <br /> rr <br /> S A M P L E CONTAINER MATRIX a co U) <br /> o o <br /> WASTE- SOIL 1 U 0 4 <br /> IDENTIFICATION LOCATION DATE TIME TYPE NO. WATER WATER SLUDGE LAB NO. <br /> Vt .l `�((tJ/ µ 3 C / X 7C Iid= 16 <br /> ,cus c It U) .- cFlAvqAl >1 <br /> &.z'&e -A ho 4 j4'<5 1650 <br /> SPECIAL INSTRUCTIONS/SUSPECTED CONSTITUENTS <br /> RELINQUISHED BY (Sig ature) DATE/TIME RECEIVED BY (Signature) RELINQUISHED BY (Signature) DATE/TIME RECEIVED BY (Signature) <br /> Yf;. <br />