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.use of Cell fornla—Health and Welfare Agency Department of Health Servlcea <br /> HAZARDOUS MATERIALS SAMPLE ANALYSIS REQUEST <br /> 'RI. A ORITY HML No ly <br /> To <br /> Explain) Aa 4 <br /> -ART 1: FIELD SECTION Esq-4'y D (7)D"'1 I -7tic73 <br /> Collector C I rl I 1 !i ' r - ry Cf rl5 Date Samplers lR �) L2M-,( Y --� Time i ?t Hours <br /> Activity: Q Enforcement ❑ ASP ❑ H.W. Property ❑ Super ❑ Othe? ❑ RCRA OPT Code <br /> Region: ❑ PMS-SACS( NCS-SAC ❑ NCS-FRESNO ❑ SCS-LA ❑ NCCS-BERK <br /> LOCATION OF SAMPLING: <br /> Name <br /> hrl J00 - Tel. NoLF �/PCC� <br /> Address Q ,,2 0 V i C-I o r Rd 4-O C' <br /> Number Street City Zip <br /> HML No. Collector's Type Of <br /> (Lab Only) Sample No. Sample* FIELD INFORMATION <br /> y�� )Ll 2 5 R{ - 4o <br /> - 19Z _ 53(, - L/U2 w c.TiL <br /> A )Ha 536 - Lf 03 .. kT-t., ne tnl e F <br /> � l 536 - L/0 (4 `.y� V, rt.tr nlc t <br /> Aa L4 e 3 b- Lf o5' Cj",A S r--Cr, <br /> Aai�3 53 (.- -� 0e tNdamA s Lcr�Iz.,. p n <br /> Analysis Requested: 0 r, 3 ic — 4 ea '4 O (o y Il r% h n LI s, z <br /> Cr <br /> Chain of Custody: <br /> 51 nature / Title <br /> Inciuslw Mt" <br /> SI aturo —v— 11,01,111,01,111,011,01,111"Oh <br /> lat <br /> Signature Title Incluslve Dat" <br /> 4 Signature Title Induslve Dates <br /> 5 Signature Title Inclusive Dat" <br /> Special Remarks <br /> (a.0.,du pllute umole 91van f0 company,etc.) <br /> PART II: LABORATORY SECTION—, <br /> Received By ZLZ / Title Date U`- Z'` <br /> Sample Allocation: ❑ HML ❑ SCBL ❑ LBL ❑ Other Date <br /> Analysis Required � '-� " � / * t"'r /`-��' / C•( "n--�r1t</J <br /> J <br /> r / <br /> f.f -/ �/ r /' /• �' /it. / � � �L / -- <br />