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,ata of Caulomia-Health and Welfare Agency Department of Health Services <br /> HAZARDOUS MATERIALS SAMPLE ANALYSIS REOL)cST <br /> R16SITY 1 HML No <br /> To t <br /> _xplain) <br /> ,ART I: FIELD SECTION <br /> 1 <br /> :ollector �") CI l t C( i n, E..-y 4 n,5 Date Sampled Time Hours�""ta � <br /> activity: 0,Enforcement ❑ ASP ❑ H.W. Property ❑ Super ❑ Other ❑ RCRA OPT Code <br /> legion: ❑ PMS-SAC NCS-SAC ❑ NCS-FRESNO ❑ SCS-LA ❑ NCCS-BERK <br /> -OCATION OF SAMPLING: <br /> � r-1 d 1 D r- _ Tel. No "� ykU c� <br /> Name \ /I,Jo 1 <br /> Address 1� yy l r_4 oy- (" I-t l <br /> Number Street City Zip <br /> HML No. Collector's Type Of <br /> (Lab Only) � Sample No. Sample' FIELD INFORMATION <br /> j <br /> 8- - - y07 CILA ACCP J r t r r' o f � - 3 Cl r2C <br /> 9-, s al.- y0 n4 pe.r t if- ft <br /> v <br /> Analysis Requested: �, /nl�� .C�'Cf•/�4 ��/ %/'�/Mf ( S - <br /> I ! <br /> Chain of Custody: <br /> InSlusiw Dates <br /> q ,•'S19nature `/� /� T Ve L• 't I� <br /> .y1ry� l )F'�J'1,.T`.��ti.if J`lti..C�J Cl.'✓1'"r- �� •1 r / � � �?�.� <br /> Z I na'tlu re I Tltla k Incluslw Dat. <br /> 3 ..p �� <br /> Signature Title Incluslw Dat. <br /> 4 <br /> Signature - Title . Inclusive Dat. <br /> ' <br /> 5 Signature Title Inclusive cat. <br /> Special Remarks <br /> (a.9.,Oupllcata sample given to company,etc.) - <br /> PART If: LABORATORY SECCTION/ <br /> f ,.0 ,� Title Date <br /> Received By — I. <br /> — <br /> Sample Allocation: ❑ HML ❑ SCHL ❑ LBL ❑ Other . ': Date <br /> Analysis Required <br /> 1 <br />