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4 <br /> Stale of California—Health and welfare Agency Department of Health Services <br /> OFFICIAL SAMPLE RECEIPT <br /> HAZARDOUS MATERIALS MANAGEMENT SECTION <br /> 1449 Temple Street 744 P Street 2151 Berkeley Way <br /> Los Angeles, 90026 Sacramento, 95814 Berkeley 94704 <br /> (213) 620-2380 (916) 322-2337 <br /> (415) 843-7900 <br /> Date <br /> Firm Name 19 ADnPS- <br /> Cri, L e l �0 2 C <br /> Address City <br /> Zip COtl¢ <br /> V L of YO <br /> �er5on Interviewed <br /> Pofsi�tion <br /> The items listed below were collected as official samples on this date as authorized by Section 66328, California Administrative Code, Title 22. <br /> Quantity Unit Size Material I.D. Number <br /> � Ga.' WtrV' ,�'no .-, onL nca.n t� 4tT' 3C —`-la3 <br /> S36 _goy <br /> dT S W conn t 1 o sl`�c Iti�tt 3c ^ `lo S <br /> lqr �• �. 1, <br /> 0 <br /> 13 to L C- It It 531^ D7 <br /> =eceipt acknowledged by C L N--.. tune ew"171 <br /> 519n /��y3'� BY <br /> AuthorizedAonnr <br />